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!

Tranquil Tuesday

Confined to barracks today due to the more volatile than usual political situation. However the sun is shining and we are allowed on the roof. Considering the alternative is snow in Halifax we can't really complain.

We all chilled in the sun, playing some Bocce ball. Michelle wasn't happy with the quality of the balls so went and made some with plaster! Marc and Katy even managed to get a rooftop workout in. A ball game of 'Foursquare" was prematurely ended when the ball was lost over the edge.

Just when the ennui was beginning to set in we had the opportunity to go to the OR to sort out our gunshot wound. Good case: patient spoke excellent English and his biggest fear was how much this was going to cost him! We reassured him that it was all covered. Our First world moans about poor wifi and water pressure put squarely into perspective! He did very well. Once I managed to solve a couple of technical issues ie no oxygen or anaesthetic gas(!)  Brandon and I got him induced, The Daves explored his peroneal nerve and plated his tibial plateau. Tourniquet troubles however: we ended up using machine number 3 a 70s throwback if ever I saw it. Yours truly managed to get it to work.

Then it was off to MINUSTAH for supper, minus a few of the group as there was a code blue in PICU. Had a very welcome bacon cheeseburger with spicy fries and a substantial measure of rum with barely enough room in the glass for coke!

Just another manic Monday

Day 3: Monday

Written over breakfast on Tuesday by the way. This is supposed to be our day off but due to the ongoing political situation we are currently confined to the compound. Hopefully we might get onto the roof for some sun and fresh air later. No water pressure at present either so definitely another day in paradise!!

We had our first official full day in the OR yesterday and it was certainly productive. First case was a complex trimalleolar ankle fracture, then an exploration of a nasty wrist injury due to a grinder. Not as soft tissue as first expected, as well as tendon damage there was crushed bone, so that was not a quick case. To round things off a fractured tibia/fibula which was 3 weeks old. This would have been a challenging case at the Halifax Infirmary and it certainly was far from straightforward here. Took a few hours to get everything lined up and nailed but the result looks perfect. Again it shows what can be done with more limited resources when you have skilled surgeons and a good nursing team! Haitian Ortho residents were able to scrub in for the cases too so even during the challenges David McCartney and Michelle Arakgi were able to impart some knowledge!

Back to our quarters where we discovered that the presidential election results were due. Given the inflammatory situation, with supporters of one party threatening to set Port au Prince on fire if they lost, it  was decided no trip out for supper! Instead a large pizza order was delivered from Visa Lodge which fed us well. Managed to amuse ourselves for the evening chatting, playing and getting to know the other members of the team. Some serious games of Cribbage went on: who knew Michelle , Marc and Katy were such card sharks?? We are all able to laugh together: Darrell the legendary paramedic being one of the entertainers of the group- he can even juggle and do magic!

As seems to be a recurring theme in my career as a reluctant paediatric anaesthetist I ended up in PICU getting an arterial stab on a newborn with an omphalocoele getting surgery today. Ultrasound was available but I ended up drawing on my dormant paeds skills and used the Force to do it by touch! The great thing about this trip is always the cross-discipline cooperation. Everyone helps everyone else: ER docs in the ICU and recovery, RT everywhere it seems for example.

I stayed up to find out the election result on twitter and to my surprise there was a winner: Jovenel Moise a former banana farmer from the PHTK ( Haiti Bald Headed Party!) and the anointed successor of former Pres Martelly. His platform was make Haiti great again by growing more bananas on the deforested land!  Already there are accusations of corruption and mentions of Trump! As to the disgruntled Fanmi Lavalas party ( Aristide's party and the party of the shot PM from my earlier entry)who threatened to set the streets on fire- their candidate came in fourth!

At the time of writing Port au Prince is peaceful and in all probability only minor demonstrations and celebrations are likely. Still confined to barracks though, no city tour for the group. I am sure we will find something to occupy ourselves. Might get into the OR later to explore a gunshot wound in an unfortunate gentleman who got shot 3 days ago. He was dropped off in a mattress in the back of a Tap-Tap taxi which made a colourful if unsafe ambulance alternative.

Anyway I hear the water is back on so a shower and a shave are beckoning. Will keep everyone updated. Marc Butler in his new found role as Cruise Entertainment Director is looking for balloons and a cable to connect his laptop to the TV so we will no doubt be kept amused!

Day 2: another pleasant Haitian Sunday

 

Writing this over breakfast on Monday. The Haitian porridge is almost worth the trip alone, sweet and spicy, just the thing to get us started on today's casualties!

Finally got into the OR yesterday for more routine stuff. While Kim, Karen and Katy sorted through a mountain of supplies I went to look after a breast reconstruction with the departing plastics team from LA. I was able to relieve one of the local staff to go and do a cleft palate case on a 15 day old, figured it wasn't the time for me to start having a go at neonatal anaesthesia.

Lunch was a welcome feast of local Creole cuisine before we got into the OR to get a couple of cases done. First up was a little old lady, 61 but she looked about 100, with a flexion contracture after a fall and a femur fracture. Got it straightened out so she will be a lot more mobile.

Next was an elbow fracture, young guy had a rock thrown at him which given the current political climate is not surprising. Thought it all went very smoothly but as is the way with these things it wasn't! Decided to stop breathing in recovery. Not ideal as the cubicles are tiny, dominated by a big oxygen tank and the suction only worked if you held the tubing in one hand and used the suction in the other! He came round but preferred coughing to breathing and unfortunately developed negative pressure pulmonary oedema! Needed diuresed and an overnight stay. Just goes to show there is no such thing as routine anaesthesia!

Just as we all got ready for supper the heavens opened and there was a torrential tropical downpour. Nearly caused an international incident at the Travotel restaurant as they didn't have many tables and a lot of patrons looked on jealously as they set up a big banquet table for our second group. Then it was back to the quarters for Cards against Humanity where the surprisingly filthy mind of Katy Van Vulpen triumphed - and she looks so sweet and innocent too!!

Air conditioning broke down during the night and all hell was breaking out in ICU and Paeds ICU with cardiac arrests and neonatal deaths. Lot of tired faces at breakfast this morning but the Ortho OR team and I are relatively refreshed and ready to go!

The mission begins:pizza and gunfights

Yesterday was a long day for us all. Started for me when my alarm went off at 230 for a 4am airport rendezvous. 12 hours and 3 flights later we arrived in Port au Prince and headed to the hospital. 

Bernard Mevs has undergone some changes and the volunteer accommodation has certainly improve. No need for mosquito nets now that it is fully enclosed and air conditioned. We claimed our bunks ( only 4 to a room now!) and headed to Visa Lodge for dinner.

We managed to inadvertently order an excess of pizzas which are now in our fridge (another innovation!). Had just enjoyed a few slices and a beer when we got a call that a gunshot was coming in and could anaesthesia and ortho come back...

Got back and got as organised as we could and waited for the patients to arrive. Turned out one was a former PM and was the victim of an attempted assassination! he was fortunate in that it was very superficial and just required debridement and closure in the OR. Would have liked the chance to get prepared in the OR but managed to make it work and he did well. Was very glad to have the expert assistance of Brandon Dsouza,a respiratory therapist who I think will be invaluable this trip as I am solo.

An innocent bystander wasn't so lucky. the other casualty was caught in the crossfire and got shot in the head. He got intubated on arrival and currently sits this morning on a ventilator. No CT scan but plain films show no bullet in the head. Neurosurgery wants to watch and wait. 2 died on the scene, which was near the Tytoo Orphanage, so that is a trip which wont be happening this time.

After getting to bed around midnight I slept like a log and am now enjoying some coffee. Thankfully not much on the agenda for today. Going to see if I can tidy up my end of the OR while Dave Amirault goes in search of patients. Doesn't look as if there will be a lack of them!