Final Haiti Trip Report - Team Sinai Operation Rainbow June 2013

FINAL TRIP REPORT  Team Sinai Operation Rainbow 2013

We had a very successful mission this past March 2-9, 2013, our fourth visit to Adventiste Hospital in Port au Prince. Our local host, Dr. Francel Alexis was there working beside us every day, clearly settling in to his role as Director of Orthopedic Surgery at HAH.  Francel demonstrated a real dedication to the hospital’s mission of serving the poor, and providing a high level of orthopedic care to the community.  Throughout the past year, we have been in contact with Dr. Francel Alexis, who is providing expert follow-up care for the children and adults that we operated on last year. Many of the hospital programs and services are becoming increasingly Haitianized, in an effort to strive for sustainability.

Mac Christophe

For example, the international volunteer services are now coordinated by a bright, energetic, and amiable young man, Mackenzie “Mac” Christophe.  Mac took care of us from our arrival at the PAP airport until our departure, worrying for our needs, and doing everything possible to make our mission efficient and comfortable. We found him to be the ultimate major domo, concierge, ombudsman, and troubleshooter.  He never stopped advocating on behalf of the patients, the staff, and the volunteers. All that, wrapped up in a trilingual ever smiling handsome young man.  Coordination of the OR equipment has been taken over by Jean Joel “JJ” Boyer, a long term employee of HAH well known to all the groups who have rotated through HAH since the January 2010 earthquake. JJ worked hard all week to make sure that we had all the surgical equipment ready and in good working order. During surgery, he functioned as an outstanding surgical technician. Kind and gentle, JJ endeared himself to our entire team.

Our 18 team members included 1 Guamanian, 1 Haitian, 1 Russian, 1 New Zealander, 1 Lebanese, 2 Dominicana, and 11 born in the USA. The surgeons were John Herzenberg, MD (Team Leader), Ahmed Bazzi, MD, Job Timeny, DPM and Lee Hlad, DPM.  The Anesthesia team included Maria Adrian, MD, Tom Fernandez, MD, Brad Cohn, MD, and Gina Muscara, CRNA.

Our PACU nurses included co-Team Leader Merrill Chaus Herzenberg, MD, Kim Hammond, RN, and Tina Jorgenson, RN.  The OR nursing staff was led by repeat volunteer and designated surrogate mother, Lucilla Hernandez RN. Lucilla was assisted in the OR by Peggy Mertz, RN and Alex Kasselman, RN.   Surgical technologist Christina Jones rounded out the OR team.

Two assistants provided invaluable help: Joanne Marasigan, Medical Student From SUNY Upstate in Syracuse, and Brittany Herzenberg, doing her senior internship from Beth Tefiloh High School.  Kris Connor, professional photographer also joined the team, documenting the week’s events.

We arrived in PAP on Saturday afternoon, greeting by Mac, who arranged two stuffed to the gills pick-up trucks to carry our 34 duffle bags (1,700 lbs) filled with surgical equipment, medical supplies, medications, bandages, and all the fixin’s needed to run a week-long surgical mission. We settled into our new digs at HAH in the volunteer bunkhouse, with overflow diverted to some unoccupied patient rooms on the second floor, thanks to Mac’s willingness to accommodate our larger than average team.  Merrill and I bunked in the physical therapy gym, sleeping on the PT treatment tables, and enjoying the air conditioning and hot water. On Sunday morning, the team unpacked the duffles and set up shop in the OR, the PACU,  and the clinic, making sure all was arranged for a busy Monday clinic and OR. While the rest of the team set up shop, the four surgeons, along with our host Dr. Alexis, ran a three hour long continuing education seminar for 21 young orthopedic residents from the orthopedic residency program at HUEH.

At the start of the mission, the team members visited a local orphanage, delivering, in true St. Nicholas fashion, goodies, and good cheer. We made it through the week without any significant complications, save for our own team members who fell ill to water borne contagions. 

The total number of cases that we operated was 38 (28 children and 10 adults)

8/38 cases were bilateral, one child accounted for 4 of the procedures (multiple wound debridements/VAC changes)

The case breakdown by category included the following:

Peds Foot/Leg            21

Peds Ilizarov                6

Arthroscopy/Knee       3

Adult Trauma              8

Detailed Case Listing:

4/30/12

1.     ORIF Left Hip Subtrochanteric Hip Fracture

2.     Remove TSF

3.     Bilateral Core Decompression for AVN hips

4.     Remove external fixator from right Hip and Femur

5.     Bilateral Clubfoot release for Arthrogryposis

6.     Femur and Tibia osteotomy for Rickets, Application of TSF, Orthofix to Femur, Tibia, Foot.

7.     I&D Infected Distal Femur/Knee; Wound VAC

5/1/12

1.     Iliac Crest Bone Graft for Nonunion Distal Femur Left (EARTHQUAKE)

2.     Bilateral Tibia-Fibula Osteotomies for Osteogenesis Imperfecta, Genu Valgum

3.     Peroneal Nerve decompression, Achilles Lengthening, Application of TSF to Foot and Ankle (EARTHQUAKE)

4.     Labrinudi Triple Arthrodesis for Neglected Clubfoot

5.     Tendo Achilles, Flexor Tendon Lengthening, Completion of Epiphyseodesis Distal Tibia and Fibula, Right (EARTHQUAKE)

5/2/12

1.     I&D Infected Distal Femur/Knee; Wound VAC

2.     Remove 8 plates

3.     Epiphyseodesis Left Femur and Tibia

4.     Lambrinudi Triple Arthrodesis for Neglected Clubfoot

5.     Adjust TSF, add toe wires

6.     Adjust TSF, Remove infected wire

7.     Arthroscopy Right Knee

8.      Osteotomy Right Femur, Apply Ilizarov Right Femur and Tibia (EARTHQUAKE)

9.     Bilateral knee disarticulations for Tibial Hemimelia

10. Medial/Lateral Hamstrings, TAL, Triple.

5/3/12

1.     Edward Mayrs 9M: Left Lambrinudi Triple for Neglected Clubfoot

2.     Samy Orphe 2M: Bilateral tibial/femoral 8-plates for Blounts

3.     Stephanie Correpond 4F: Left Clubfoot Release with Anterior Tibialis Transfer

4.     Miramir Durosier 27F: Achilles Lengthening and Claw Toe reconstructions (EARTHQUAKE)

5.     Romulus Burtho 20M: Wound debridement, VAC, Left Tibia Injury

6.     Katiana Flenrimond 16F: Right Femur Lengthening with External Fixator (Orthofix) for Congenital Femoral Deficiency

7.     Carline Coral 38F: Bilateral Hip Core Decompressions

5/4/12

1.     Left ACL reconstruction

2.     I&D Infected Distal Femur/Knee; Wound VAC

3.     Left naviculectomy and calcaneocuboid fusion (recurrent clubfoot)

4.     Right Lambinudi Triple Arthrodesis (Recurrent Clubfoot)

5.     Right Gastrocnemius Lengthening and Hamstring Lengthening for CP

6.     Remove Bilateral TSF from Feet/Tibia, apply Casts

7.     Ilizarov Right Femur Osteotomy (EARTHQUAKE)

8.     Claw Toe repair after compartment syndrome (EARHTQUAKE)

9.     Bilateral Knee Flexion (Artrhogryposis) Capsulotomies, extension/shortening Femoral Osteotomies

10. Blounts- Bilateral Tibial Osteotomies and Bilateral Distal Femoral 8 plates

5/6/12

1.     I&D Infected Distal Femur/Knee; Wound VAC, Application of Spanning External Fixator Right Femur/Tibia

Teach a man to fish...

Merrill instructing Haitian nurses on the Propac

At the request of the Adventist Hospital nursing director, Team Sinai's nursing staff prepared a formal teaching program for the local nursing staff of Adventiste Hospital. A total of 8 lectures were given during the week, on topics ranging from EKG interpretation, Post Anesthesia care, Types of Anesthesia, Pulmonary Embolus, Pediatric and Adult Physical Assessment, and Malignant Hyperthermia. Our nurse teachers included Gina Muscara, CRNA, Kim Hammond, RN, Tina Jorgenson, RN. The Haitian nurses came in to the hospital to attend these lectures even on their off days, and were very appreciative, even to the point of excitedly running after Kim Hammond throughout the week with EKG strips for her to affirm their readings. Adventist serves as a clinical site for many nursing schools in the Carrefour district of Port au Prince, and we often saw large groups of nursing students, in their school uniforms, including formal nursing caps.

Professor Bazzi and the Haitian Nursing Students

Burger King crowns all around at Mary Lou's Orphanage.

During a visit to Mary Lou's Orphanage on Sunday March 3rd, Merrill delivered a talk and workshop to the kids on Health and Hygiene, including hand washing and infection prevention.  Merrill left a refillable Purell dispenser for the kids, with a recipe for home made Purell consisting of Alcohol and Glycerine. Mary Lou was very appreciative that Team Sinai walked all the way up the mountain to her modest orphanage in Carrefour, bringing toys, food, Burger King Crowns, and joy to the 18 orphans she cared for. Mary Lou and Merrill connected, and in a tender gesture, Mary Lou and Merrill walked arm in arm all the way back to Adventist Hospital.

Mary Lou and Merrill walking back to Adventist 

Dr. Bazzi lecturing to the HUEH ortho residents.

Our good friend Dr. Lew Zirkle (http://signfracturecare.org/about/about-sign-founder/), who has been many times to the General Hospital in Port au Prince teaching the HUEH orthopedic residents, had suggested that we invite the HUEH residents to HAH for some formal teaching. We set up a four hour program that included various lectures by Dr. Ahmed Bazzi of Johns Hopkins, Drs. Hlad, Timeny, and Dr. H. Topics included pediatric elbow fractures, tendon transfers, pediatric femur fractures, calcaneus fractures, neglected clubfeet, tendon transfers about the foot, clubfoot, and supramalleolar osteotomies.
Job Timeny acted as our simultaneous translator. Our host, Dr. Francel Alexis, gave lectures on Tibia Vara, and on Introduction to the Taylor Spatial Frame, in his native Creole. At the end of the four hour lecture marathon, the 21 orthopedic residents from the Haitian University Hospital assembled with us for a proud group photo on the steps of Adventist Hospital.

HUEH residents and the Orthopedic/Podiatric Team Sinai docs.

The Real International House of Pancakes

Our Dominicana mammis, Lucialla and Maria, never fail to surprise us. Our team woke up this morning (our last full day) to the sound of a sizzling skillet and the sweet smell of butter milk pancakes. As Tom from New Zealand, Ahmed from Lebanon, Alex from Russia, Joanne from Guam, and our other team members from coast to coast sat around the room eating the delicious pancakes, team leader John joked that this, "was really the International House of Pancakes." Fully fed, the team head to the hospital to complete 5 last operations (making the final number of surgeries this week 33). Finishing around 6:30 pm, we scrabbled to make it to the Auberge, the Four Seasons of Port-au-Prince, for our 7 pm dinner reservation. 

Our final feast together, we kept with the Operation Rainbow tradition and gave out awards to each team member. Though we typically distribute the team t-shirts at the beginning of our trip, we decided to switch things up a bit. This year our 18 team members had to work for their navy blue Team Sinai Operation Rainbow tees. With their award, they were also granted a team tee.   

Another post to come tomorrow,

BH 

Our team gathered on the hospital's front steps
(with the exception of Tina--our hardest worker busy in pre-op)

Gina accepting her Operation Rainbow award

The surgical team from USA

John and the Hispanolia Islanders

Medibabble to the Rescue!

To those of you who fear that one day technology and machinery will replace human-beings in the workforce--you are absolutely right. Sharing 4 translators amongst the OR, PACU, pre-op, and the three wards, the language barrier appears to be bigger than ever. Brad Cohn's Medibabble app, however, has been there saving our behinds this past week. Since the app does not require a 3G or wifi connection, our team has been able to use it all over the hospital. The app comes preprogrammed with questions that require a yes or no answer (in some cases, a smile or frown and scream). The best part--it actually reads the question out loud to the patients, sparing us the embarrassment of attempting to imitate the Haitian dialect.

Overall, our patients are (thank god) doing well, and we can all leave on Sunday knowing there will be no serious complications.

Looking forward to our last full day tomorrow,

BH

Feeding one of our patients Plumpy'nut

Waiting in pre-op for his operation

"King Camil" in his crib with donated blanket and Burger King name tag

A Taste of the Dominican Republic

After a terribly long day, our team came back to the bunkhouse to find our two Donicana team members, Lucilla Hernandez, an OR nurse, and Maria Adrian, anesthesiologist, slaving away over a small hotplate in our kitchen (the back corner of the house). We weren't surprised, however, as the two wonder-women wake up early to cook breakfast to share with the team, and always make an abundance of flavorful rice and vegetables for dinner. Tonight, however, knocked the shoe covers off the doctor's feet. After running from the hospital to our little house in the pouring rain, we opened the door and were welcomed by a sweet, savory aroma. Cooking was a "south-of-the-boarder" inspired spaghetti. The cooking pot was vibrant with yellow corn, red peppers and green veggies. Maybe it was in comparison to our exhausting day that made the food taste all the more delicious (or maybe the fact that it was prepared with so much love). Over half way through the trip, our team has grown to be more united. We shared stories and laughed, a necessary relief after the eventfully heavy day.
Watch the video to get a sneak peak of our team after hours.

Merrill enjoying her home cooked meal and a foot massage from Maria

More updates on our patients to come, 

BH

Like a Chicken Without His Head

**This post was intended to be published Tuesday, March 5th, but a precarious internet connection here in Carrefour and the Benadryl I took that night postponed the actual posting**
As I reflecting on today, I become exhausted simply doing so. We had scheduled 9 operations, and ended the day doing 8, thanks to 3 no-shows (not uncommon here--sometimes families don't have enough money for a tap-tap for transportation or refuse to go outside when it rains because of trauma from the earthquake 3 years ago) and 2 add-ons. Some surgeries, like the removal of an 8-plate, lasted only an hour, while others, particularly those involving an external-fixator, almost exceeded 4 hours. I'll try and spare you of the gory details--but one case involved the removal of an 8" piece of dead, cracked and yellow, exposed tibia (something you would never see in the U.S.). The patient, an older man with 5 kids fell off his motorcycle about a month ago, was initially treated at a small outside hospital by "ORIF" (open reduction internal fixation) with a plate that became horribly infected. He was transferred to HAH, where our host Dr. Francel Alexis removed the infected plate and applied an external fixator. Dr. Alexis consulted with Dr. H (who was disturbingly excited when he saw the case), and we offered to work on it with Francel first thing in the morning. Another patient, a 24 year old woman with a severe clubfoot, had been wheelchair bound her entire life until now. Though her operation will require intensive physical therapy, she will soon be able to walk and live the independent life she only dreamed of.
Aside from the OR, our three PACU nurses were busy running the pre-op, PACU, and post-op, ensuring the patients wouldn't develop any infections or illnesses. Kim, our lovely nurse practitioner, gave three lectures to the Haitian nursing staff and nursing students explaining patient physical assessment and readings of an EKG, amongst other things. They all loved it, and came up to Kim throughout the day, excitedly showing her their patients EKG strips.
Our day began at 7 with a meeting on the steps of the hospital, including a prayer offered up by Dr. Ahmed Bazzi, and ended at 9, occasionally popping in the hospital to personally monitor our patients. Overall the patients are doing well, and I'm sure that Wednesday, a day that our doctors will split their time in the clinic and OR, will hold just as much work.
Only a few more days to go,
BH  

In the PACU 

Nurse Kim carrying a patient upstairs to the pediatric ward

Lost in Translation

 Keeping with a tradition started by Scott Nelson, we began our day with a morning meeting on the steps in front of the hospital. Our team leader (Papa John) reminded us of our goals and intentions; to practice medicine at the same standard as in the U.S., and to include the local Haitian staff in our day, teaching them as we go. We had a busy clinic today, evaluating roughly 25 people (primarily kids). Unfortunately, our team only being at HAH (Hospital Adventist de'Haiti) for a week, the doctors had to select who they deemed most fit to operate on. Hopefully, the orthopedic team coming next month will be able to take on the rest.
At the end of the clinic day, we saw the final five patients, all orphans, all with neglected clubfeet. Apparently there is some kind of Foot Patrol that rounds up kids every now and then to bring them to hospital for evaluation. All needed surgery badly, but unfortunately, all five had bloody diarrhea, probably amebic dysentary, and so none were scheduled for surgery this week. The Adventist hospital volunteer pediatrician, Dr. Audra Wise, wrote the kids prescriptions for medications for their diarrhea, and we made sure all five left with a hearty meal of rice and beans, a blanket from the ladies of W.E.L.C.A., and some toys and Burger King paper crowns.
In between clinic patients, our docs operated on six children. More to come tomorrow, when the clinic is closed but the O.R. will be in full swing. Its a balmy 95 degrees here by day, and a not too uncomfortable 75 degrees at night, often cooled off by tropical rains. The Haitian people are truly lovely, appreciative, and proud. We're all learning a lot, including some Creole, and enjoying our mission.
The blog's title "Lost in Translation" was inspired by our end of day trip to the bar down the street. A few of us sat downstairs drinking Prestige and juice, and began to question what the staircase in the corner would lead to. Maybe it was a disco? We could all use a 10 minute dance party. When we asked the bartender if there was a dance floor upstairs, he replied "hotel, hotel!" With his lack of English and ours Creole, we may never know what that dark stairwell leads to, but if we find out, I'll make sure to tell you!
See you when the internet connection is on my side,
BH

Waiting for hours to be seen

ArtArthroClinic

One of the orphans with clubfeet standing with Peggy

Rose Mina, our patient of 3 years
returns for another operation 

Gina teaching the nurses

The Calm Before the Storm

We woke up to a cool, minimally sunny Sunday this morning. The slight wind and cloudy skies assured us to expect rain later in the day. Dad (Dr. H) introduced the group to the Adventiste tradition of a morning meeting as a means of centering our thoughts, preparing for the day, and indulging in a long and thoughtful prayer in Spanish intoned by our Dominicana head OR nurse, Lucilla Hernandez. Our nurses, OR techs, and anesthesiologists emptied and organized the umpteen duffles that we brought (estimated at nearly two tons), setting up the pre-op, post-op, and OR rooms for the week's surgeries. Meanwhile, our surgeons were upstairs giving lectures to 21 local orthopedic surgery residents from the General Hospital (HUEH) in downtown Port-au-Prince. Dr. Herzenberg (father dearest) covered neglected club foot and calcaneal fractures, while Dr. Job Timeny (who doubled as a medical translator) gave a club foot presentation. Dr. Lee Hlad taught the residents about supramalleolar osteotomy and posterior tendon transfers and Dr. Ahmed Abazzi covered pediatric upper and lower extremity fractures. Our host, Dr. Francel Alexis, gave two outstanding talks on basic principles of the TSF and tibial varum.  The Haitian orthopedic residents were entranced, asked lots of questioned, and promised to come back in smaller groups throughout the week to work in the OR with our doctors. All left with a souvenir Baltimore Limb Deformity Course (deformitycourse.com) goniometer, printed lecture notes, and a BLDC course manual was donated to the HUEH library.

After a lunch of rice and beans provided by the hospital, we walked about a mile and a half to Mary Lou's Orphanage. Mary Lou is 29 years old with one child of her own. She cares for all of the children by her self, and the orphanage consists of 2 full sized beds and 2 bunk beds. There is one washroom and an outdoor courtyard to play in, along with a terrace garden. We were greeted by hugs and beaming smiles. There, we taught the 20 children how to properly wash their hands, followed by distributing mini hand sanitizes and ingredients to make their own sanitizer locally (all you need is alcohol and glycerin!). We also brought fruits and vegetable plants, and helped them plant them in their garden. Finally, we distributed candies, crowns donated by Burger King, jump ropes, soccer balls, and lots of stickers and coloring books.

A Warm 90º Welcome to Haiti

A fearless Joanne securing the bags

And alas we have arrived! Our team successfully managed to lug our 19 50lb duffle bags from Baltimore to Port-au-Prince. Don't be fooled, however, as our trip from the Port-au-Prince airport to Hospital Adventist was far from smooth. After dragging our bags through the dusty streets, we were welcomed by two drivers, one with a 4 seater pick up truck, the other with a 5 seater SUV. As our team of 15 looked at our bags, at each other, and again at the bags, the one word that crossed everyone's mind was "clown-car." Meanwhile, our Haitian drivers assured us not to worry, and proceeded to stack duffle on top of duffle until a mountain appeared before our eyes. Once we all miraculously managed to squeeze into the cars, we embarked on trip of life or death. Picture the Wild West--no police to enforce the law, no stop signs speed bumps or traffic lights to control traffic, and no rules (so appreciate the next time a cop pulls you over for going 40 in a 35). With each pothole our car went over, we would all start laughing hysterically, guessing who's bag fell off that time. When we finally arrived at Hospital Adventist, we unpacked our supplies and put our clothes and food in the guest house. We are currently listening to Spanish Christmas music (provided by our Dominican super-stars, Lucia & Maria), eating our microwavable TV dinners discussing the days to come.
Keep tuning in for updates once the real action starts to unfold!
BH

Lee loading the bags onto truck

Clown-car!

Lucilla and Maria from the Dominican Republic

Home for the next week!

From left: Job, Alex, Ahmed, Gina, Christina, Lee,
Merrill & John

Lee Hlad, DPM : The Apprentice

Lee grew up in upstate NY in a community were cows outnumbered people 4:1. He completed his undergrad degree at Mount Saint Mary College in Newburgh NY, and received his podiatry degree from New York College of Podiatric Medicine. He completed his residency at Grant Medical Center in Columbus, Ohio. Lee is now 8 months into a limb lengthening and reconstruction fellowship with Dr. Herzenberg at Sinai Hospital in Baltimore. He has been married to his beautiful wife Danielle (also a podiatrist) for 6 years and for now, they have a little puggle, Gertrude. Lee has never embarked on a mission trip, but hopes to make this the first of many. He is looking forward to building lasting relationships with those who volunteer and the patients encountered.