A Medical Economics Web Exclusive

One FP's moment in the surgical sun

On a mission trip to Haiti, an FP rediscovered his surgical skills in the middle of a goat pasture.

By Michael W. Klinkner, MD
Family Physician/Cary, NC

It was another bone-rattling bus ride in Haiti. The potholes in the dusty road were so big that they resembled dinosaur-slaying meteorite strikes. As we drove along, children would run after the bus smiling, waving, and yelling "Blan! Blan!"—their word for foreigner—in hopes that we would throw them candy.

We were there to offer far more. The 20-odd passengers on the bus, hailing from all over North America, constituted a mobile medical clinic intent on relieving pain and suffering in this impoverished Caribbean country. We had all signed up to serve under the umbrella of Mission to Haiti, an organization based in Miami. Our part of the group included my wife, Pam, who's a registered nurse; my daughter, Lizzie, then 14; and John Hester, a nurse and dental technician whom I met at a free health center in Raleigh, NC. Little did I know that John would later become my surgical assistant and scrub nurse.

This particular day, our destination was Nan Palmiste, a tidy village of thatched huts, pastel-colored stucco homes, and manicured thicket fences. As a local pastor directed us to a parking spot, we caught a glimpse of our patients: Several hundred Haitian men, women, and children, all in their Sunday best, milled about next to a small school building.

Nan Palmiste didn't have a structure large enough to house our medical activities, so we set up in a goat pasture under the shade of mango and plantain trees. A motley assortment of chairs, tables, and picnic benches arranged to make patient stations and a pharmacy. Villagers scooted the resident goats, pigs, and fowl to an adjacent field—not that they stayed there.

Within an hour, we were examining patients, dispensing medicine, extracting teeth, and wiping down children with scabicide. The low-pitched din of human chatter filled the air, punctuated by the baas, oinks, and clucks from our curious animal neighbors. Every so often, we were bathed by a Caribbean breeze.

The relative calm was suddenly broken by the sound of panic. People gasped as a path opened up through the crowd. A worried man was running toward us, cradling a crying girl in his arms. Her eyes were wide open in terror, and the mud on her school uniform indicated a recent accident. As they came closer, I could make out a bloodied leg and, to my shock, a dangling, lifeless foot.

The story rushed back and forth through our interpreter. The girl's name was Veronique, and she was 8 years old. She had fallen off her bike onto a trash pile containing old sheet metal. As I examined the wound, my heart sank. A deep, jagged oblique laceration split open the back of her ankle all the way to the heel, completely severing her Achilles' tendon and exposing the distal tibia. The gash was filled with dirt and debris.

"Oh my God," I said, shuddering. "What am I going to do with this mess?"

Ordinarily in remote Haitian villages, wounds like this would be packed with mud, crudely bandaged, and left to their own fate. Sometimes a voodoo priestess would offer chants and potions. The wounded usually would lose the foot, and perhaps the leg. Tetanus and overwhelming sepsis were possible. These poor villagers had no local doctors, no transportation to a hospital in Port-Au-Prince, the capital city, and no money for treatment even if they got there.

John Hester and I thought hard and fast. I had a tattered, olive-green Boy Scout knapsack filled with autoclaved surgical instruments, donated suture material, sterile gloves, and drapes. Our group's makeshift pharmacy had bottles of irrigation saline and all the antibiotics and pain meds we would need. And John could raid the dental supplies for syringes of lidocaine.

The next issue was the surgeon—me. Although my residency training in family medicine was top notch, my experience in Achilles' tendon repair was limited to assisting on two or three operations. I hesitated for a moment, remembering the adage, "First, do no harm." But the procedure was pretty straightforward, and I had faith in my suturing skills. Besides, other options for this youngster were bleak at best. I looked up from the knapsack to John. "Let's do this," I said. John smiled and nodded.

Without another word, the entire team sprang into action. Veronique was placed on a cleared picnic bench, her dangling foot at the end. Pam got face to face with the frightened child and talked to her softly in English. Even with the language barrier, this calmed our patient into stillness. Other nurses slowly poured saline on the wound and cleaned the skin around it. Someone took on the critical duty of shooing flies out of the operating theatre. John readied a surgical tray while I washed my hands with Betadine and dictated what I would need from the knapsack. The observation gallery grew by the second.

I painted the skin thoroughly with Betadine and started my local block. Our dental syringes were equipped with very fine needles, so it took forever to numb the wound area, but at least the injections didn't seem to bother Veronique. I pinched the skin with sharp tweezers to be sure the anesthetic had taken. She didn't register any pain.

Next, I turned my attention to the wound. There, at the posterior ankle, was the gaping hole. It was a filthy mess, but happily, I could see the distal stub of the Achilles poking through the dirt like a pearl on the sea floor. We used several bottles of saline to flush out the muck. Then I re-scrubbed, applied more Betadine, and draped the wound.

Thankfully, the proximal fragment also was easy to find. The sheet metal had made a razor-clean cut. The tibia was exposed but unharmed. I squirted out the rest of the dirt, debrided the dead tissue, and checked for neurovascular damage. I couldn't see where any nerves or major blood vessels had been severed.

"Okay, you can do this," I told myself. While I had John gently place Veronique's foot in plantar flexion, I clamped the two ends of the tendon close to each other in proper alignment. Then I placed sutures in four quadrants, cinched them tight, tied, and cut. "This is going to work," I thought.

I finished suturing the tendon as if I'd done it a thousand times before. The subcutaneous tissue was healthy and easy to stitch together. Nylon skin sutures finished the task. The crowd murmured, and I heard someone say, "Beautiful."

Now, to make sure it healed well. Veronique's wound was washed again, then dressed and bandaged. A crude splint was fashioned from gauze, ACE bandages, and duct tape. Our pharmacists concocted broad-spectrum antibiotics to cover the usual pathogens plus tetanus, and measured out cough syrup for pain control. Detailed instructions were patiently conveyed to Veronique's father in Haitian Creole. We handed him a suture removal kit, which he graciously accepted as if it was Excalibur.

Finally, everything we could think of was completed. Dad scooped up his daughter, cradled her bandaged leg, and smiled as he waded home through the crowd. But there was no time for celebration. Our surgical adventure had eaten up a big chunk of time, and there were 100 or so patients yet to see. We trudged back to our stations.

The clinic ended, the mission ended, and all too soon we resumed our typical American lives—bloated, over-fed, self-important. The speed of the transition was shocking … from the poorest nation in the hemisphere to the richest in 90 minutes.

Although we settled back into our jobs, school, chores, and social life again, we soon felt an inner emptiness, a call to a higher purpose. We needed to go back to Haiti. It was like a craving for an essential vitamin that would make us healthy, sane, and whole.

So we traveled to Haiti the following summer, this time our younger daughter, Sarah, came too. When we arrived at the mission camp, it was like a family reunion. We saw dear old friends, and made new ones. My girls were quickly absorbed into the local community. I'd watch their two blond heads in a cluster of Haitian kids as they played soccer with a mango pit.

As before, we boarded a bus to Nan Palmiste. Nearing the village, I recognized the thatched huts, the stucco houses, the neat thicket fences. A throng of patients was waiting for us in the goat pasture. In no time at all, the team had the clinic up and running. My girls treated children for scabies while Pam and I saw patients at our respective stations. The familiar hum of our operation created a relaxed feeling.

Then a buzz of excitement arose from the crowd. Someone said, "Hey, Dr. Mike, look who's here." It was Veronique, and she was riding her bicycle toward us. Riding her bicycle! She was pretty in her school uniform of white blouse, orange skirt, white socks, and patent leather shoes. She zoomed up to my station, dropped her bike in the grass, and leapt onto my lap. "Merci," she said, kissing me hard on the cheek. A crowd swelled around us and camera flashes came from everywhere.

I started to shiver as she turned her leg around to show me her scar. I had to blink a couple times to see it, but there it was—a thin pale line, barely visible. "Incredible. It's perfect," murmured John Hester. "Yes it is," I said, choking up, tears in my eyes. Veronique pumped her foot up and down to demonstrate that all was well. It was astonishing.

Next came a blur of hugs, backslapping, and more photos. Veronique reveled in her role as star patient. But we couldn't celebrate too long. It was time for the team to get back to work, and for Veronique to return to school. We hugged one more time, and then she hopped from my lap. She straightened her clothes, mounted her bike, and smiled at us. Then she pedaled across the goat pasture and onto the dirt road, kicking up a little dust.

Michael Klinkner. One FP's moment in the surgical sun.

Medical Economics

Aug. 20, 2004;81.