Our first day at Labo District Hospital

The Rotary did things right with a sound system and tents in the front yard for people waiting to be seen in clinic.

First day in Labo.   I woke up at 12:30, 3:30 and for keeps at 5:00. It rained all night and was very humid in the morning. We made good time getting to the hospital about 7:30. Unpacking was slow mainly because we brought a lot of things we won't use and some of the drugs that we will need were wantonly tossed into a box filled with  shipping peanuts. Finally everything found a home and we did our first cases starting about 1:30 pm. I put a 13 year- old boy to sleep for a cleft lip repair. His age was not certain because his mother abandoned him. The guy was very brave about the IV. It's a little eerie to put someone to sleep using just a blood pressure cuff and a pulse odometer for monitors. I've had to cross-fill an isoflurane vaporizer with halothane and I'm not confident in the vaporizer output. It seems to shut off if I set it for less than 2%. Anesthetizing  infants tomorrow will be interesting.

View from the operating room. The bull seemed pretty tame, no tether.

Our second case was a ten year-old for a keloid excision from the right pinna. The mass looked very ugly so I hope he gets good result. I used a LMA for this case and all went smoothly. I have five cases for tomorrow so I hope the day starts on time. I have to be mindful about cutting corners: the rule of tens, for instance. One of the local docs had a two week old for a cleft lip repair. I stood by the 10 weeks, 10 pounds, 10 grams of hemoglobin. I hope the baby gets fixed before too long but it' s not right to take chances on these kids.

Final post on Haiti Adventist Hospital

Thursday was an operating day. We brought Pierre, the gentleman who fell off a roof on December 2, to surgery to examine his wound from Friday and put an external fixator on his wrist fracture. He also had a pelvic fracture so we had to bring him to the operating room in his bed. The door jamb had been freshly painted so I felt bad about scraping it as I wiggled the bed through, but it would have happened some time. When I got him into the operating room I gave him some Valium and ketamine to facilitate transfer to the operating table. There was a delay so I blocked his brachial plexus while he was still in bed. The nerve stimulator wasn't entirely to my liking but the block worked well just the same.

 While we were in the operating room a lady came in with a fungating growth on her thigh. The tumor is a malignant complication of neurofibromatosis. She came in because of odor and infestation with maggots. The surgery for this is bound to be pretty extreme and she will need blood, so we weren't able to operate on her that week.

 The high point of my day came when Mlle. Bonham came in for the 3-11 shift. She is the most cheerful and helpful nurse on the Adventist staff.

There was no surgery scheduled for Friday so Jen and I went to the Bernard Mevs/Project Medishare hospital in downtown Port au Prince. Surgery didn't start for a while after we arrived, but I got to visit with Judith, Francia and Dorothy; the anesthesiologists on the Bernard Mevs staff. I worked with Francia and Dorothy when I was there in May.

I finally got to do a case by myself! While Jen was giving the anesthesia for a hysterectomy,  I put a lady to sleep to drain a huge (I am in no way exaggerating) abscess in her buttock.  She had reportedly gotten an injection of iron dextran a couple of weeks prior to admission. Her hemoglobin was 7 g/dl when she came in, so the iron didn't seem to do her much good. I graduated medical school in 1980 and this is the worst I've seen. Here's a link to the video: http://youtu.be/PiYCX53HQ_I

I'd like to close out this chapter by thanking Hugh and Kathleen MacMenamin. Hugh is an orthopedic surgeon, Kathleen a developmental pediatrician. I was lucky to have the chance to work with them.

They came from outer space

Today was pretty quiet. I had a mosquito bite on my arm this morning, so I was offered and accepted a doxycycline tablet.  I found out that it is a very bad idea to take doxy on an empty stomach. I felt better after I threw up but had to lie low for a couple of hours as well. In the afternoon Jen and I organized supplies in the operating room. I went to the Deli-Mart and bought a couple of bottles of lemonade that sat well on my stomach. Just before dinner Greg, the bio-med technician, showed me a YouTube video of an alien spacecraft that has been sighted next to Mercury. It is cloaked and only became visible when a solar flare engulfed it.  Greg thinks it could have been there, observing us, for millennia.

He may be right. I’ve always thought that if I were going to invade Earth, I would set up a base camp on Mercury, landing when the sun was interposed between it and Earth. I’d build my camp somewhere in the terminator, the zone between light and dark that would not be so extreme in temperature. I’d use my solar powered equipment (us little green men are green, you see) to build the rest of my fleet and launch my assault when Mercury and Earth are closest.  That way I’d have the sun at my back and conserve the most important element in the universe: the element of surprise.

I expect that Rosanne (the scientist) and I (the visionary) will be called upon to help defend the planet. Fear not, the enemy will never penetrate our troposphere.

Haitan Adventist Hospital: A busy day in and out of the operating room

After dinner Monday night one of the staff asked me to start an IV on the gentleman, Pierre, who fell off a roof last Friday.  He needed blood before we operated on him on Tuesday. Jen and I tried peripheral IVs for half an hour to no avail. The blood was in his room, in a thermos, so I didn’t want to wait until morning.  I went down to the OR, found one of our few central line kits and brought it up to the ward. I was fortunate in that the light was good in his room. It was very hot and I had two of his relatives holding on to him, but even so he nearly contaminated the field. I got an external jugular catheter to thread centrally and flushed all lumina after the transfusion. We’ll see if the line stays in over night.

I slept poorly Monday night. It’s noisy and not very dark. Tuesday morning I found out I’ve been washing my hair with conditioner (vs. shampoo).  This may explain why my hair doesn’t feel too clean.  I’ve never been clear on what the difference is between the two, but it is noticeable after a day or so. I checked on Pierre before conference. His breathing seemed a bit better than Monday and His SaO2 was improved. The dressing on his CV line had come off but the catheter was still in place. I showed the nurse, who was not at all happy about the central line, how to dress it and asked one of the permanent staff who speaks Creole to give them an in-service.

We got the operating room going in a very timely fashion, under the circumstances. I helped Jen in the operating room while going back and forth with the Haitian nursing and medical staff about Pierre.  They were anxious about the central line and worried about taking him back to surgery.  I explained several times about the need to examine the wound from Friday to look for any sign of infection and that placing an external fixator on his wrist fracture would not pose any risk of further blood loss. I thought we’d come to an agreement to operate on him that day, but an hour later when I asked one of the aides to help me fetch him he told me that the case was on hold, pending consultation with ophthalmologist and neurosurgeon. At that point I decided to stop trying to get him to surgery that day. We’ll hope to work on him on Wednesday or Thursday.

There was a power failure in our common room/sleeping quarters after work. Greg and Randy were champions, tracking down the problem and putting in a fix to get us through the night. They’d both put in a full day prior to this but seemed happy as larks to have another problem to solve.

We are a little short of spinal drugs. This vial is labelled "Bupivacaine 0.5%" and I think it is in a hyperbaric solution of dextrose. I sent photos to Young Kim, the anesthetist from Columbia-Presbyterian, with whom I worked in Egypt, to ask for a translation before I shoot it into someone's back.

Haitian Adventist Hospital

We had our first plowable snow fall on Saturday night in St. Paul. It was a good warm-up for the road crew as it was only a couple of inches of fluffy snow and there was not so much morning traffic, being Sunday. 

My first good news was from the American clerk, telling me I better get my passport replaced as it's becoming unacceptably worn. I spent about $90 on adding pages a year ago, so this was not happy news. The only other notable event was a two-hour delay on the tarmac in Miami. Seems they overloaded the aircraft with fuel and had to take some off. This involved two fuel trucks: one that didn't work and one that did. Traffic was light leaving the airport. The presidential palace is still in ruins but the streets seemed cleaner than August 2010.

Monday morning we made rounds with Hugh. The most interesting patient is a gentleman who fell of a roof on Friday. He had seven hours of surgery to place a sign nail in his L humerus and repair an olecranon fracture. He also has a pelvic fracture that has not been treated surgically. Post-op he had fluid problems and his hemoglobin was 7.5 on Sunday. This morning he still has rales but the edema is better. He had a SaO2 of 86% that increased to 89% after moving him around in bed. We plan to put an external fixator on his wrist fracture and examine the wound tomorrow. He can't see out of his right eye and the pupil responds poorly to light. I suspect it's a post-op optic neuropathy, as he was lying on his left side during surgery, his systolic blood pressure ran in the 60s-70s and he got between five and ten liters of isotonic fluid. Not much to do on that but wait and hope.

After rounds Kathleen, Jen and I went to visit an orphanage run by the family of one of the HAH staff members. The place seemed pretty full to me, but the only students there were the boarders. The children in the neighborhood who attend the school were excused because today is a holiday. Jen shared the Sinter Klaus candy that her boyfriend Erik gave her. The paper and colored pencils that Kathleen bought were a big hit, too. 
After lunch Jen and I worked in the operating room, checking out the anesthesia machines and organizing our supplies. They have nice new monitors since I was here in August 2010. We have six cases booked for tomorrow.

Hotel Windsor

I can't leave the visit to Cairo without mentioning the Hotel Windsor. The building has been a private residence and later a British officers' club. It was bought by SwissAir in the late sixties and is now privately owned. The building and its furbishings are pretty old, but everything works well. Seeing the switchboard is well worth the price of admission. The breakfast was tasty and the staff friendly. My room was clean but a bit musty. The water was hot and the toilet flushed. I had a little problem with no-see-ums getting in through the screens.

This is the telephone in my room. I didn't make or receive any calls, but I had a chance to practice my Arabic numerals. The hotel is in the downtown area, away from the tourist hotels and the Egyptian Museum. It was about one-fourth the cost of the Four Seasons. I'd stay there again if the opportunity came up.

And here is my policy on hotel recommendations. If you haven't started reading xkcd, you should.

Hotels

Vacationing in Cairo

We had a free day on Thursday, a holiday celebrating Egypt reclaiming the Suez canal. I went to see the Citadel of Cairo and looked around two of the mosques. Compared to a church a mosque seems very open and airy, probably because there are no pews, statues, altars or paintings. The buildings themselves were very impressive.

Stop me if you've heard this one. A Buddhist, an atheist and a Jew walk into the mosque one morning...

Thursday evening the plastic surgery department treated us to a cruise on the Nile. We left the dock about half an hour before sunset. Here's a picture of Dr. Jihan Mohasseb, an Egyptian plastic surgeon living in Germany, in front of the Cairo Tower. The tower was built in the late fifties and is lit up at night.

Dr. Riham El-dasouki, the lady below with the big smile, is one of the plastic surgery residents at Aim Shans. She was charged with making our visit comfortable and she did a marvelous job. From the very first day she anticipated our needs and made sure that anything we wanted would appear. The Nile cruise was her last  function and she made it memorable.

The buffet included lamb, turkey, eggplant and a variety of side dishes. The hospitality in Egypt was the best I've encountered in the middle east.

 We didn't talk much about the revolution but I got the sense that it was very much on people's minds. One of the students from Mansoura went to Tahrir square early on and was attacked by the police. He came home with a broken arm, and his father didn't speak to him for three days. He felt terrible about this when he realized how frightened and angry his father felt, but he didn't regret participating. Another guy told me how his friends would organize a demonstration by telephone when the internet was shut down. I think the mood was generally hopeful about the future of a representative government in Egypt. Everyone that I talked to made it clear they were in favor of a secular state, but some of the Coptic students were worried about the possibility of an Islamist government. I think their concerns were justified by the violence that broke out on the day I left.