Just fixin bones

---

Today was a big day of operating. Not much else to report, really, and likely not of huge interest to people who don’t do orthopedic surgery! Of course I have to be fairly vague on details when it comes to clinical stuff out of respect for patient privacy, anyway.



The first case was a radius fracture in an older gentleman who had fallen onto a curb and broken his arm in two places. I was particularly delighted because I had seen this gentleman in clinic the day before and booked him for surgery, but he had a family friend with him and they wanted to discuss it with his immediate family and then come back. I said that was fine, but if they wanted surgery the next day they had to arrive before 8am, fasting, so that the appropriate arrangements could be made in a timely fashion. No stranger to developing countries, I fully expected him to show up at 3pm, if at all. But no! He came diligently prior to 8am, fasting, and ready to go. I will admit that I was shocked! But very pleased. Daryl (the senior resident) and I did this case by ourselves. Other than Daryl having to cut the screws to the size that we needed with a large pair of bone cutters, we were able to treat it using pretty similar equipment to what we would have had at home. Daryl did a beautiful approach (the cutting through the appropriate structures to reach the bone) – good job, buddy! This poor gentleman had his hand totally dislocated from his forearm in the cast he had been in previously, so I am very glad we were able to offer him surgery. I suspect he would not have regained a functional hand otherwise.



Next was a case of a bone fracture through a tumor in the bone (in general, tumor tissue is not as strong as bone so if you have cancer tissue the bone is prone to fracture. It can also be very painful to the patient even before it fractures). This one I am afraid I am less happy about. Without getting into the minutia of treating tumors in bone, in Canada there are many steps of investigation that you go through before you actually treat a pathological fracture (i.e. try to figure out what kind of tumor it is, if there are more of them in the body, etc) but we did not have the luxury of the resources or time required for such a workup in Haiti. We did what we could but cancer care in Haiti is still very very limited so I am not sure what the future holds for this unfortunate patient.



Finally, we got to tackle a difficult polytrauma patient with multiple fractures which had been waiting for us since before we had arrived. This was a young patient who had been involved in a motor scooter crash and had multiple fractures all through her right leg, all of which required surgical stabilization. To treat so many breaks requires some specialized resources, so we could not just push her to the operating room the moment we touched down. First of all, we needed to have some blood available to give her because so much surgery carried with it a risk of significant blood loss. From what I understand, if you wish to have blood on hand to transfuse for a patient, that patient has to have two family members go to the local Red Cross to donate blood. Then they will release one unit of blood, after it has been appropriately matched to our patient. We had hoped for four units… so that was going to take some time. Next, we needed to make sure we had the right types and sizes of metal implants to use. We did not, but we were able to come up with some work-arounds to make do with what we had available. This included putting a long rod designed to go into the tibia up into the femur, instead! (We put one in the tibia, too). Once we designed our detailed surgical plan and figured out all the implants, screws, drills, clamps, etc what we would require, all of that had to be carried down to the surgical processing department (i.e., the room around the corner) to get sterilized. With a limited capacity for the number of surgical sets that can be done concurrently, this, too, took time.



So, on Friday afternoon, all the pieces had fallen in to place for our trauma patient to get the surgery that she needed. Daryl and I got to work with a number of Hatian residents scrubbed in to observe and help. Step 1 of many (the reduction of the femoral neck) proved a bit tougher than we had hoped so we waved the white flag and Dr. Coles scrubbed in to use his Magic ET Finger (as I call it) to get the bones back into place where they are supposed to go. Daryl and I would have gotten it eventually, but with still so much surgery to go I did not want to spend an excessive amount of time on the very first part of the procedure if it was not necessary. After that tricky step, things progressed very well. I had to use Daryl’s brawn to cut a bunch more screws to size, but at the end of it all, all her bones were back in place and we were very pleased with our work, though very sweaty and rather tired.



Did I mention that Dr. Leblanc fixed a big gash in her face at the same time? Plastics for the win, again!



At the end of it all, Tigger and I took the patient to ICU to recover. She had been totally stable throughout the procedure but the Haitian nurses were more comfortable having her in a setting with more supervision, which we thought was quite reasonable. Unfortunately, when we got to ICU they pointed to a tiny, walled in “isolation” room for her. There was already a stretcher in there which did not look like it would fit through the door to come out, and I did not think that her current bed would fit through the door to go in. After a fair amount of time looking helpless and confused, eventually a guy named Roc showed up to assist. Turns out our stretcher did fit through the door (with millimetres to spare!) and the room was just big enough to squeeze both beds in. Then we lifted up the whole mattress from the OR stretcher and kind of dumped her into the new bed and extricated ourselves from it all. Tigger and I couldn’t help think it was reminiscent of moving a corpse…. But the strategy certainly worked and it was only unorthodox to us, not to them.





Most delightful to all of us was that we managed to finish in time to meet up with the rest of the group for dinner! We went to a place with live music, which made for a great atmosphere. I had “creole goat” which was pretty good. I tried a glass of white wine but that was a mistake. I will stick to Prestige (local beer) and rum and coke for my adult beverages from now on!

---

Photos

Lunch on the roof
Our favourite spot of solitude. In years past if the gang violence was too high in the area, volunteers were not allowed on the roof due to concern of stray bullets. Fortunately all was calm on this trip.

Evening entertainment
Dinner and a show!