Prepared by John Herzenberg, MD
Introduction
Team Sinai spent one week at HAH (June 10-17, 2010). We were an 18 person team, primarily from Sinai Hospital of Baltimore. This report is based on our experience there. During that week, our team included one orthopaedic surgeon, two orthopaedic fellows, one podiatry resident, one anesthesiologist, one family practitioner, one physical therapist, six nurses, one prosthetist, one central strerile tech, and three helpers. We worked closely with Dr. Scott Nelson, Orthopaedic Director of HAH. We also “drafted” several volunteers from other teams to work with us (Loma Linda residents, medical students, and nurses from an Oregon team that overlapped our stay). We performed 54 surgeries, and operated past midnight on four out of seven nights. Thirty-one cases had anesthesia by our team anesthesiologist, the remaining twenty-three had anesthesia administered by three Haitian anesthesiologists. We worked hard to accommodate both the elective cases that had been prepared for us, as well as the emergency and urgent cases that were brought in. Examples of cases we performed: hemiarthroplasties for hip fractures, pinning of hip fractures, osteotomies for femoral neck non-unions, SIGN nailing for tibial and femoral fractures, SIGN nailing for nonunions, posterolateral bone grafting for tibial nonunion, plating of femur fractures, ORIF ankle fracture, 8-plates for tibia vara, release of knee/ankle contractures, many clubfoot surgeries, CP tendon lengthening, Fassier Duval nailing for Osteogenesis Imperfecta saber shins, I&D of abscesses, VAC changes, amputations, bone transport for tibial defect (Ilizarov), open reduction of neglected shoulder and hip dislocations (from the January 12 earthquake) and iliac crest bone grafting for various nonunions. In addition, we staffed an orthopaedic clinic on three days, and a Ponseti clubfoot clinic on one day. Average orthopaedic in-patient census was 45. About 50% of patients we operated were below age 21. One third of our cases were earthquake related.
HAH was a 70-bed hospital where not much orthopedic surgery was done before the January 12, 2010 earthquake. It is one of the only hospitals in PAP that survived intact after the earthquake. There is only one thin crack in the structure, and it has been certified by the Army Corps of Engineers as safe and in no need of repair. We were told that the original architect/engineer who designed and built HAH was from California, and that he built it to withstand earthquakes. Immediately after the earthquake, nobody wanted to enter any building in PAP, fearing the aftershocks would cause more damage. Thus, for a short period of time after January 12, 2010, operations at HAH were being performed in tents in the parking lot. Dr. Scott Nelson came to HAH shortly after the earthquake, and stayed for 5 months until June 20, 2010. During those five months, he and others did a tremendous amount of organizational work, and developed one of the most active and advanced orthopedic services in PAP. During the week that we were there, many patients were transferred from other medical facilities (such as MSF and Medishare) to HAH with complex orthopedic injuries, including hip fractures and spinal fractures. Drs. Richard Schwende and Kaye Wilkins were commissioned by the Pediatric Orthopaedic Society of North America to survey potential sites in Haiti for POSNA members to staff, and wrote that based on their survey in late March 2010 that “HAH was the best-equipped and administratively managed hospital among those visited”. http://www.posna.org/news/Haiti_Apr8Update.pdf
Physical plant
HAH is in the Carrefour district of PAP, and is about ¼ mile from the Adventist University. It is about one hour’s drive from the PAP airport, in a mixed residential/commercial neighborhood. There are nearby markets and stores within a few blocks from the hospital. The entire hospital compound is protected by a wall, and has a guarded gate entrance. HAH is a two story concrete hospital, with attached chapel. There is no elevator to the second floor, but there is a covered circular ramp, so that patients could be wheeled on gurneys to the second floor. The first floor contains the ER, OR, pre and post-op wards, radiology department, pharmacy, cast room, clinic, and administrative offices. The second floor has numerous private rooms (one patient per room), numbering about 24, and more administrative offices, and a volunteer’s break room. Air conditioning is present in the three OR’s, break room, cast room, and clinic room. There is a separate, adjacent pediatric ward and OBGYN ward in front of the hospital, about 50 feet away. There are several donated large military style tents on the hospital grounds that are used as step-down units, and there are also numerous small tents on the hospital grounds where many ex-patients and Haitian staff (translators, for example) are staying.
HAH has its own water supply piped directly from a nearby spring. This reliable water supply was actually developed after the earthquake. There is also an onsite purification unit for drinking water. Two generators on site provide back up power if the city grid goes down (almost a daily occurrence). There is good cell phone reception and the hospital has free Wi-Fi available. Due to generator issues, we did have to operate several times in the evenings briefly by lantern/head lamps. In the basement, there is a hospital kitchen that provides one meal daily to patients and volunteers.
The majority of the ex-pat volunteers sleep in a breezy, covered veranda on army cots and under mosquito nets. A few intrepid volunteers pitched tents on the roof of the hospital. Some volunteers stay in the unused private rooms. There is a sufficient number of flush toilets and cold showers available for the volunteers to be comfortable. One meal per day (lunch) is provided by the hospital for patients and volunteers. In keeping with Adventist tradition, the kitchen is strictly vegetarian. Volunteers also bring their own food, which can be prepared in the adjacent air-conditioned volunteer break room, which is equipped with dining tables and a microwave oven. Hospital housekeeping provides dishwashing service. The volunteer sleeping area and break room are guarded 24 hours/day to discourage theft. We never encountered any problems in this area.
Staff
There is a full time Medial Director, Dr. Lesly Archer, who is a Haitian OBGYN. He trained in Montreal, and maintains residences in both Canada and Haiti, but has been continuously present in Haiti since the earthquake. He is charming, trilingual (English, French, and Creole) and was very helpful. They have about three obstetric deliveries per day at HAH, which take place in a separate, adjacent OR facility that I did not see. Dr. Archer does elective OBGYN cases in the main OR facility.
Until recently, Dr. Scott Nelson was the Orthopedic Director, but he left on June 20. Dr. Terry Dietrich of Appleton, Wisconsin tj.dietrich99@gmail.com, is his replacement, but is not due to arrive until November 2010. Dr. Dietrich has served as a volunteer with Dr. Nelson at HAH previously, so he is familiar with the system. For the four month interval until Dr. Dietrich arrives, HAH is relying on part time and short term orthopaedic volunteers, including Dr. Mark Perlmutter, an orthopedic hand surgeon from Pennsylvania, Dr. Barbara Minkowitz, a pediatric orthopedist from New York, and Dr. Karl Rathjens, pediatric orthopedist from Dallas, Texas. A team from New York Columbia Presbyterian is also scheduled to arrive in November. Dr. Lars Hansen, president of the Haitian Orthopaedic and Trauma Association, visited us but we did not see Haitian orthopaedic surgeons operating at HAH.
There are three Haitian anesthesiologists, but their schedules require coordination, and they are generally not available after hours.
The wards are staffed by Haitian nurses, but due to the large volume of patients, dressing changes, and complex problems, it is highly recommended to have a full cadre of volunteer nurses. There is an ex-pat nurse, Brooke Beck brooke.bbeck@gmail.com who has been working for the past four months. She coordinates many patient care aspects as well as coordinates the volunteers. She is scheduled to rotate out of HAH in September, and work with another NGO in Haiti. A new expatriate nurse, Jessica Scott has arrived, and will be staying for the foreseeable future. There is also a Haitian American floor nurse coming this fall, which should be a great help in keeping the hospital running efficiently.
The OR has Haitian orderlies, and central sterile personnel for decontamination and instrument sterilization. There are Haitian radiology technologists in the x-ray department.
Haitian doctors staff the ER and peds ward. Many volunteer groups have augmented the Haitians with US family practice or ER docs.
Numerous volunteer translators are ever present to help the teams. While French is spoken widely by the educated class, including nurses and doctors, most of the patients speak only Creole. It is customary for the international volunteers to provide a gratuity to the Haitian translators before departing. Such tips are greatly appreciated by the translators, and other local personnel, many of whom are working for free, and truly depend on the generosity of the international volunteers.
Early on after the earthquake, there was a full time ex-pat relief administrator, Dr. Andrew Haglund, who helped coordinate the reconstruction efforts at HAH. He left about two months ago, and is sorely missed. Recently (late June), a full time ex-pat assistant administrative director has arrived, Nathan Lindsey nlindsey@llu.edu mobile +509-3491-6539 along with his wife, Amy, a nurse. They will be staying for an extended tour of duty. This should be a great help to further develop the long term viability and growth of the HAH. The challenge for volunteers, both long term and short term, is to scrupiously respect the feelings and sensibilities of the Haitian indigenous personnel, encourage them to become invested in the workings of the hospital, and ultimately become sustainable rather than dependent on expatriates.
Affiliation with Loma Linda University (California)
HAH is affiliated with the worldwide network of Adventist Hospitals. HAH has a special relationship with Loma Linda University’s Global Health Initiative. They are also partnering with CURE.
Coordination of volunteers since the earthquake has been through LLU. The contact person at LLU is Alex Sokolov asokolov@llu.edu
At any given time, there are 25-35 volunteers working at HAH. Some groups also have ventured out to staff clinics in the refugee camps and tent cities.
The hospital is affiliated with the Seventh Day Adventist church, so the Sabbath is celebrated on Saturday not Sunday. The OR’s and clinic are closed on Saturday, except for emergencies. Sunday is a regular OR day. Scott Nelson started each day with a 6:30 inspirational meeting on the steps of the hospital. This time was used to read some inspirational passages from sources such as Mother Teresa, to relate stories about what it was like after the earthquake, and to discuss organizational issues. It was conducted in a culturally sensitive, non-denominational fashion, which was important for our team, which included many orthodox Jews.
OR facilities
The OR suite at HAH comprises two large OR’s and one small one. There is a changing room, toilet, large well-organized storage room for orthopaedic sets, a small storage room for sterilized sets, refrigerator (used for blood, drugs that require refrigeration, and drinks), and large central sterile room with two large sterilizer units that can handle any large tray. Between the two large OR’s, there is a small pharmacy storage area. There is not a specific room in the OR that would handle the volume of equipment that Rainbow brings, but there are one or two rooms just outside the OR suite doors that could potentially be used for this. The large OR’s can accommodate any big case, including use of the c-arm. The small room is appropriate for simple cases.
There is a modern c-arm (OEC 9600) with a double monitor and printer. This can be wheeled from room to room. There is a plethora of orthopaedic gear including the following: Synthes large and small fragment sets, cannulated screw sets, Synthes battery powered drills, external fixator sets (Orthofix, Synthes, Hoffman, and Taylor Spatial Frame), hemiarthroplasty set and implants, SIGN nail set and a pedicle screw set for posterior spinal fusion. There are also many surgical instrumentation trays available that are appropriate for orthopaedic cases. There are many wound VAC machines, and a modest supply of consumables for the VAC’s. Suction and Bovie electrocautery were available in each room. For tourniquets, we used Esmarch bandages, and also brought a supply of Hemaclear disposable tourniquets.
Anesthesia facilities
The anesthesia machines and monitoring machines in the OR were old, and only partly reliable. Oxygen was readily available in the OR from tanks, and these could be transferred to the floor if needed. This is similar to what we have encountered on previous missions to Nicaragua and Ecuador. The Haitian anesthesiologists favored spinals over general, and used Ketamine liberally. It is highly advisable to bring a Propack and i-stat. Laboratory facilities at HAH are rudimentary. It was possible to obtain a CBC quickly. We had an i-stat which allowed us to get nearly instant blood work. Microbiology and Blood Bank services are available only off-site. Obtaining blood for transfusion is an ordeal, with the patient’s family having to bring a sample and request to the central Red Cross facility in downtown PAP. Two days is a routine time frame for obtaining blood.
Hospital supplies
There are three fairly cavernous (think last scene of “Raiders of the Lost Ark”) storage rooms which have been well organized and labeled to store the enormous amounts of equipment that was donated after the earthquake. Still, maintaining the supply chain is a challenge, particularly for sterile drapes, gowns, and other OR consumables. We brought a moderate amount of sterile gowns, drapes, towels, lap sponges, and gloves, which came in handy. The hospital routinely washes bloody lap sponges, dries them, and then resterilizes them for re-use.
Orthopaedic Clinic
There is one clinic room and a cast room. Both are air-conditioned. Additional rooms could be made available if needed in the nearby ER suite. There is a digital radiography machine, which stores hundreds of images in its memory. Efforts are being made to obtain hardware that would allow transfer of these images to a PACS. There is also a film radiography machine in the x-ray department, but this was rarely used due to the need to pay for consumables (film and chemicals). Orthopaedic clinic was held three days per week, including one morning of Ponseti clubfoot casting (20 babies). Patients hand-carry their own prior medical records and hard copy radiographs, and are very reliable about bringing them. Most patients have cell phones, so reaching them is not a huge challenge.
Security and Safety
Prior to our mission, there was concern about security and safety issues, based on reports of violence in PAP and kidnapping of MSF workers. Happily, we encountered no problems whatsoever. We felt safe and secure within the HAH compound. We did not experience any episodes of theft or pilfering. The patients and staff at HAH were welcoming and appreciative. Some of our team members ventured on foot a few blocks outside the hospital to purchase soft drinks and fruit at the local market. They reported that the chief safety concern was from road traffic, not people. On two occasions, members of the group went on a supervised walking tour outside the HAH compound to the nearby (1/2 mile) Adventist University site, which has become a tent city. The locals were warm, friendly, and were happy to engage in conversation. Our team included three younger volunteers (age 16-19), and they all had a very positive experience.
No member of Team Sinai became ill during the trip. All were taking malarial prophylaxis. Two members had needle stick exposures, and started taking anti-retrovirals until the HIV test from the involved patients came back negative (24-48 hours later).
Summary
HAH is a very viable site for North American volunteers to consider. It is currently perhaps the most advanced orthopaedic facility in Haiti. The facility is comparable and in some ways superior to other sites in Nicaragua and Equador and Colombia that I have worked at over the past 12 years. There is a generous amount of existing orthopaedic surgery sets and instrumentation, but restocking is a challenge. Teams coming should communicate with the hospital well ahead of time to determine what supplies should be brought down.
Until Dr. Dietrich arrives in November, it will be challenging for teams to get as much accomplished in a short time as we did under the supervision of Dr. Scott Nelson. Nonetheless, the needs are great, and the potential impact that volunteer teams have is tremendous. The local needs are for both pediatric and adult types of cases. Orthopaedic surgeons, nurses and anesthesiologists who go to HAH should be comfortable treating both children and adults. There is much earthquake related trauma sequelae, as well as fresh trauma, and elective pediatric orthopaedics.
Volunteer groups need to partner with Loma Linda University for coordination purposes. LLU is well organized, and even provides malpractice insurance and health insurance to the volunteers. They keep track of various volunteer groups and individuals to insure that there will not be excessive overlap of manpower. Loma Linda does charge each volunteer $15/day to cover the cost of food (one meal/day) and airport transfers.
The Sinai Hospital team had a remarkable and positive experience, and to a man, expressed interest in someday returning. In fact, we are currently making tentative plans to return in December 2010.
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