First venture to theatre.

The days in Haiti seem to start beautifully, especially with the chance to be awake and alert at 4.30am.
I slept relatively well for my first night – which surprised me a little! My bedroom has no natural means of ventilation apart from the holes in the breeze-block walls, at the top, which provide for a connection to the next room, and the window with the insect screen meshwork linking me to the corridor (to the bathroom and charcoal kitchen.) And while waiting for my body to acclimatise to the temperature difference every little bit of exertion brings on beads of sweat, which turn rapidly into drops, and then little streams of perspiration, (which may be a source of amusement of the Haitians, but a source embarrassment to me) and so a night with virtually no air-movement was not appealing. But what a wonderful invention fans are! And with a night when there were no power cuts it meant that I slept well, lulled by a gentle, albeit artificial, breeze, and the constant drone of the motor obscuring most of the outside noise.

Very few people were walking the streets at 5.00am, the sky was clear, and the sun just rising. Even the usual smells of daily living were yet to fully develop, but even so, it was harder to pray than I expected... Probably a combination of being away from home and nervous for the future.
Another welcome “shower” and gradually the household comes together.
Breakfast today was toast and home-made peanut butter (best poured rather than spread), coffee – strong and black – and the option of very western cornflakes – but accompanied by evaporated milk.

At about 7.45 the accompanying team arrived: I have been assigned Yotaire as my interpreter. He is married to Nadia with one daughter Rachelle (15 months) Yoataire speaks good English, and, I am assured, good Spanish as well. He has worked as a teacher and in computer studies – spending over 15 months studying in the south of Nigeria. (Robyn in the interim will translate for Dale the physiotherapist.) Major – another church member and friend of Robyn is our chauffeur for the day. (As well as being our driver Major is our water carrier – drinking water comes in sachets of about 300 mls and several of them are comfortingly stored in the freezer providing a ready supply which might be cool or solid ice depending on how long it has been in the fridge.) Major is a motor mechanic and it seems has a ready supply of cars for our use – but just whose vehicles they are is unclear! Driving on very rough roads and dodging pedestrians, cyclists and motorbikes is fast becoming normal, but I am still fascinated by the state of disrepair most of the vehicles are in.

The hospital is about half a mile away from “home” and like many in hotter climes is painted white and set on a hill. We are reluctantly let through the barrier (a feature every time) and soon bid farewell to Major.
From the outside the hospital appears much like most of the buildings in Cap Haitien with an air of shabbiness and disrepair, and further exploration and familiarisation does nothing to dispel this impression, but rather to set it in concrete – which is what a lot of the hospital structures could do with too.
There are the inevitable introductions to be made: to the Medical Director – himself a surgeon - and then to find the theatre staff.

There are three theatres – which are equipped with ancient surgical and anaesthetic machinery. It has clearly not be possible to generate a contract with any one company and so everything represents a mix of suppliers. Each theatre has an air-conditioning unit of sorts – and they all work to varying degrees. There is no piped gas of any description, and the only gas available is oxygen, and that is in large, unmarked, cylinders which are attached to the anaesthetic machines by rubber hoses and a form of clamp. The colour coding that is used in England is not applied here, neither does there seem to be any gas-specific connectors that are a legal requirement in the UK – devices to prevent the wrong gas being delivered to the specific delivery device - but we are not in the UK... Oxygen is a wonderful drug, that all of us love and depend on, but like so many things in life (for example food and drink): too much is not good, and can be dangerous. So to find out that this is all we have to “drive” the machines and “carry” the anaesthetic agents to the patient is worrying... but at least we do seem to have plenty of it.
Living with the disposable mentality of the UK – an ethos applied to equipment rather than patients or personnel – it is strange to find here so much is re-used, or attempted to be re-used. Spinal needles and ET-tubes (medics will understand, and the rest may not want to!) are, in the UK and NZ, things which are used once, strictly on a single patient basis, and are then, needless to say, disposed of immediately when the procedure is finished. But here they are saved, washed, put through some sterilizing procedure, and then used up to 5 times more... And this is a country which has a significant percentage of the population to be HIV positive which makes the practice of re-using anything vaguely needle-like somewhat surprising. But ever the pragmatist: I can understand that it might be better to do something with less than perfect equipment than to do nothing because there is nothing else...
Gauze swabs are made on the premises from rolls of gauze which are cut, folded, packed, wrapped in aging tea-towel sized strips of cotton. Again standards are different from the UK where each pack is strictly counted by two people at every stage of use (to minimise the risk of losing one in a patient, and it seems superfluous to note that here there are no radio-opaque markings in any of them) and here they are freely available for everyone surgeon, nurse or anaesthetist to use.

I am pleased to have brought my theatre “scrubs” with me from the UK as it seems everyone supplies their own, which does provide a certain rainbow effect to the theatre: with red, and yellow, and pink and green all represented, as well as others...

Dr Carmelle Leconte is splendid in yellow! Carmelle is fluent in English, French and Creole (and I suspect Spanish as well). She is the only permanent anaesthetist here, having worked in anaesthetics for 27 years. She trained in Haiti and Paris. She is assisted by occasional trainees – who also are sent to Paris and various other places. But amazingly the bulk of the practical work is done by Anaesthetic Nurses, and to date they have all been trainee Anaesthetic Nurses. (I wonder if the system is based on the one used in the USA where it is common for nurses to manage the cases.) And here they seem to be very good.
For my first case here I was asked to “supervise” the re-fashioning of a colostomy (again the medical savvy will know) and in a 1 year old. Now I have done a fair amount of paediatric anaesthesia in the past – but in my UK hospital it is deemed to be a highly specialised practice, and limited to those who tackle children most, if not all, of the time. And a child is defined as being under 13 years.... So to be faced with a 1 year old, for a 90 minute procedure, was daunting... The prospect was made worse by the most modern of the anaesthetic machines, the only one that could use sevoflurane (I’ll leave that for the anaesthetically minded) breaking down (internal airpipes were disconnecting whenever gas was asked to flow down them – and despite being stripped down in theatre, and sticky tape being used to try and hold the pipes on it would not hold) While all this was going on the child was just lying on the operating table, with no-one to hold him, and no-one to even watch him. Thankfully he went to sleep. But once it was apparent that we would have to use an “older” machine, and it was wheeled (protesting) into theatre we could get round to the operation. And the Trainee Anaesthetic Nurse did it all!! She had calculated the expected doses of drugs, and after checking with me, used them, and intubated the baby and hand-ventilated the child all the way through, until expertly extubating at the end. I was simply there as a supervisor And the child was fine... Which was a relief to me!
Second case in Haiti was rather more “hands-on” being a laparotomy for gun-shot wound. The patient – a 49 yr old woman – was bleeding, and it had to be stopped. Blood transfusions are difficult, and usually rely on family to help provide.
Equipment failure is common: just before one case the power supply failed, and suddenly everyone was rushing around pulling out all the electric plugs. There was a fire outside theatre up an electricity pole, but it was dealt with Haitian style by someone (staff or public, relative or patient? It wasn’t clear) up a ladder pushing apart the burning electric cables. It seemed to do the trick and the power was restored very soon. And there was also the time when my torch was the only illumination for a case as both theatre lamps were broken.

Unsurprisingly the bulk of the earthquake related surgery has been done, and is now much more in the domain of Dale and other rehabilitation personnel. But so many of the cases are needy and attempted successfully in far from adequate conditions, and it must stand as a tribute to the staff here.