David S. Drozek, D.O.
Haiti
After the earthquake in Haiti, feeling the desire to do something to help, several from OUCOM and the OU community joined forces to put together a relief effort to Haiti.
Since my return, I have carried a deep sadness and a sense of helplessness. During my time and travels in Latin America, I never before had encountered a problem that I couldn't imagine some solution to; until Haiti. The problem seems so overwhelming and human shortcomings so significant, that I simply can't "get my head around" the problem in Haiti. Restoration for Haiti will need to find its source outside of man!
Here are my observations while in Haiti:
On our arrival in Haiti after a couple of long days of travel:
I am tired and hungry; have a headache and want a shower and clean clothes!
But, I have a bed to sleep in, under a solid, safe roof; power bars and granola bars, and a table to sit at with friends to enjoy dinner tonight. I have a shower with running water and an abundance of clothing to pick from. I have electricity and medicine and even a fan! I have a vehicle to take us where we need to go, even with air conditioning! I have a cell phone and can email and call my family and friends for free with ATT this week!
When I leave Haiti I will get on an airplane and meet my family at the airport, drive home in my car, probably have dinner at a restaurant, sleep in my own secure bed, and forget to think about all the people in Haiti who don’t have the things I have!
My first impression of Haiti was that of a stark barren landscape. As we approached the border from Santo Domingo, Dominican Republic, the landscape along the southern edge of the islane resembled the US desert south west; barren hills and mountains with beautiful patterns of color in the rock, scrubby growth of small trees, prickly pear and saguaro cacti. Unlike the US, these were interspersed with platano bananas and palms.
Clusters of simple homes, surprisingly many of them crudely made of wood, thin logs split into slats, as well as the more usual concrete block homes. Goats wandered around eating whatever, and small plots of sad looking crops were being attended by dark people.
When we first crossed the border, the road into Haiti was a narrow white strip between white limestone cliffs carved in spectacular shapes both by nature and by man harvesting the natural lime for construction material, and a body of water, the opposite shore appearing a few miles across the calm surface. No boats or fisherman were visible, no homes, no people other than the lines of vehicles negotiating the white path, each identified by a plume of powder revealing their position in the distance.
As we approached the first village, the signs were now in French, replacing the more familiar Spanish of the DR. Despite power lines, there was no evidence of light or electricity in any of the homes. People milled around outside some cooking, some eating, most just sitting, no soccer games, not much purposeful activity. It was Sunday, and as evening approached, more and more people were mobile with clean clothes and Bibles in hand.
There was only a rare bus, unlike my experience in Central America. But of course, it would not be possible to drive old school buses across the Gulf to Hispaniola. Instead, public transportation was predominantly by elaborately decorated pickup trucks with two feet of tube metal railing supporting an elevated truck cap, giving cover to the crowd of people seated on benches in the truck bed.
As we approached Port au Prince, we began to see evidence of earthquake damage. It was difficult to distinguish with certainty at first, since many half constructed homes, long abandoned, as evidenced by the plant growth within and around, had piles of gravel and sand scattered around, reminders of projects started when money was in hand in better times. Some of these had cracks and noticeable chunks of concrete missing, but it was difficult to be sure the cause.
Then we began to notice finished homes with damage, most commonly at first in the surrounding security walls, many with gaps filled with rubble. As we entered the urban area, neat piles of rocks, gravel and chunks of concrete dotted the sidewalks in areas remote from any visible damage. Again, it was difficult to discern what was construction material and what was debris from the quake.
Major destruction then became evident, but much more scattered than what I had expected from what the media had led me to believe, but of course why would they concentrate on what appeared normal? There were buildings completely collapsed, only a pile of rubble remaining, without a hint of the original structure. There were the majority of the structures standing with no visible evidence of damage, and then there were structures with all levels of destruction, from cracks to missing walls and collapsed roofs.
Tuesday Morning Feb 23
Sunday our group split up to more effectively use our talents for the most good. The anesthesia residents and plastic surgeons went to Quisqueya, the medical control center for medical relief efforts. The have a web site: relief.quisqueya.org.
This is a Christian school that became the headquarters for U.S. military assistance and a staging location for medical relief efforts. The class rooms have become dorms for medical professionals from around the globe who have come to help. The military has set up two large tents with AC that are filled with meds and supplies, available to anyone in their network.
Each evening there is a meeting of the leaders from each group present and assignments are made to various medical facilities around the area based on skills and needs. Transportation is provided. Morning and evening meals are provided to the groups. The service is free to the volunteers, but $50/day is suggested to cover expenses.
The rest of us, two family practice residents, a Haitian American nurse from NY, Jesse, the carpenter husband of one of our residents, and a work team from DELTA are concentrating in the clinic of Lilivois. This clinic is situated in a town of about 1500 where most of the homes were damaged or destroyed. About 200 were killed in the quake. The clinic was providing care with limited staff and supplies since the quake. Via the efforts of DELTA, they are now part of the Quisqueya network.
The clinic was still under construction, and is a sound facility. The OR was not functional, but it works very well as an acute care center. After the quake, the staff physician was delivering babies and did some amputations in the open air around the clinic, due to fear of entering the building. We are not doing any surgery there, but will transport patients to another facility as needed.
Yesterday the residents joined a Haitian doctor in seeing patients in the clinic. We had several folks severely dehydrated, including one with sickle cell. We gave them all several liters of IV solution and analgesics to help their severe headaches. We don’t have lab, and the communication is pretty limited with our translators that we never really determined if there was a cause of the dehydration other than lack of water and exposure.
In the afternoon I took a walk with the clinic director around the neighborhood. He showed my his damaged house, with his family camping out in front of the house. He showed me his recently constructed church that was flattened. He showed me where people were living in tents and under tarps, awaiting food and shelter. He told me again and again, “Take a picture of this! Send it to people who can help! We need food. We need medicine. We need help building our homes.” It was a very moving an personal experience to walk with this man through his devastated neighborhood, hear the stories of his friends and neighbors, some who died, the rest seeking to survive and rebuild their lives. I am sure his story is repeated many times over.
People were engaged in hauling water from somewhere. I didn’t see anyone cooking or eating. Many folks were sitting in whatever shade they could.
The clinic is in the center of this community. The need is great! We certainly are meeting a need like I never have before. I can’t help but wonder what would have happened to the six who received IV fluids if we hadn’t arrived with the needed supplies! They all walked out, a bit wobbly, but smiling and expressing gratitude.
More later!
Wednesday AM Feb 24
Yesterday at the clinic in Lilavois we struggled through about 60 patients. The struggle was lack of translation! The clinic director, a recent pharmacy school grad, speaks some English, Spanish, French and Creole. He was attempting to help the residents in his limited English, but was constantly being pulled away to answer questions about construction, give direction in the pharmacy and with crowd control, and to talk with various people who interrupted him for unknown reasons.
Our best translator, Guerline, a Haitian American nurse from New York, was busy running the rehydration area. She functioned pretty independently, having a vast experience in ICU, ER and surgery postop. She was bouncing around between multiple patients with IVs and the residents.
I began asking the people waiting to be seen if anyone spoke English or Spanish. We did find one volunteer, Sandy, and artist and aspiring novelist who wants to write about the Haitian plight. His English was very rough, and required a great deal of effort to work through. But, we were able to see some patients with his help.
Toward the end of the day a pastor arrived who could translate well, which sped along the process greatly. Tomorrow we are told there will be three Haitian translators present. I expressed the concern that next week we will need more if we are to do the clinic work well that we have before us.
The first couple of patients I saw were trauma related; a lady with external fixation of a fracture of her leg. I checked and cleaned her wounds, which looked to be healing well. Two of her three children were killed in the earthquake. We made arrangements to refer her to an orthopedic surgeon and to get x-rays to decide if the metal hardware is ready to be removed.
The next patient needed his cast cut off. He was told he could have it removed a week ago, but couldn’t find anyone to do it. We removed it with wire cutters that the construction guys lent for the job.
Most of the patients complain of stomach pain that started after the earthquake. I would imagine that gastritis and stress ulcers would be likely. The people continue to live in a high state of anxiety, terrorized by aftershocks, lacking food and clean water. The adrenal levels must be continuously running at high levels. They are in a constant hyper vigilant state of “fight or flight” as they seek to survive.
Last evening we met up with the anesthesia residents and plastic surgeons to see how they were doing. Our attempts to communicate by phone, email and text had all failed. They were in high spirits, excited about the things they were doing to help. They are staying at the Quisqueya school complex, and working at a private hospital called CDTI where they are concentrating on wound care.
The plastic surgeons have been doing flaps to cover amputation sites and skin grafts to cover open wounds. The plastic surgery fellow removed a neck tumor, probably a thyroid cancer from one patient. The anesthesia residents are under the supervision of an excellent teaching anesthesiologist. The first year resident performed her first pediatric anesthesia on a four month old. The senior resident was at one time monitoring three sedation anesthesia patients at the same time. They are all doing the bulk of their work in the emergency room area since the Ors are currently being used by a team of French plastic surgeons.
The Mexicans have a hospital ship in the harbor, and fly surgery personnel in to the hospital every day. Germans, Canadians, Argentineans, and many more countries are all cooperating in the effort!
The surgery team related that on Monday afternoon they too had a panic in their hospital, at the time our patients in the clinic ran out of the building. None of our team members felt the tremor, but the Haitians have been so sensitized, they feel it! They had to close down surgery afterwards, since none of the Haitian staff would come back inside the rest of the day.
Yesterday we drove by the airport on our way to Quisqueya. It is certainly a hub of activity. Vendors are set up all around. Tent communities are everywhere. People were in line to meet travelers arriving, or to leave on the reactivated commercial flights. Helicopters were coming and going, as were military trucks of all types. U.S. military personnel with full uniform and automatic weapons lined the perimeter providing security and maintaining order. People were flowing to and from containers where they were receiving tarps and boxes marked “Samaritan’s Purse”. It was a moving scene to see our military in an important life saving role, and to see the cooperative relief effort seeking to meet such a tremendous need.
We have begun planning a mobile clinic for next week when our reinforcements arrive. There are many communities that lack basic care and the Haitian pastors that have arranged for our accommodations are anxious that we visit some of them.
More to come!
Wednesday evening Feb 24
We have a change of plans! Life as a missionary in Honduras often required plan B, C, D and so on. We are moving to plan B!
The work at the clinic of Lilavois has decelerated. There were only 46 patients today, which our two residents, Haitian American nurse and I saw with our translators and Haitian staff. The Haitian doctor didn’t make it due to illness. We finished up the clinic in about half a day.
Our day at the clinic started late. We have two vans that transport the construction crew and medical folks each day. We had arranged to pick up three translators this morning at a designated location at about 8:30. They were not there when we arrived, so we packed one van with the work crew and one resident, and the rest of us waited in the second van. We waited, and waited, and waited! We tried to call our DELTA contact person, but the phone lines were all tied up. I tried texting him, iPhone to iPhone. It worked! We then received word from our Haitian contact which my DELTA contact was able to reach with a Haitian cell phone who then called the translators on their Haitian cell phones who said they were on their way! So we waited some more! Then we received a text that the interpreters were probably told their work day was 10:00-4:00, meaning they thought they were to be picked up at 10:00. By this time it was 9:45. I figured we would have to give them some Latino time and not expect them until well after 10:00.
By this time, expecting only an hour ride, my second cup of coffee worked through my system. Faced with at least an hour drive over bumpy roads, I left the van by foot in search for a place to relieve myself. There was a church nearby with a school. So I walked in and asked two ladies in Spanish and English if I could use the bathroom. They both looked at me as if I was crazy, talked among themselves in Creolleand laughed. They then pointed at a door down the hall, which proved to be exactly what I was looking for! When I returned to the van, another member of our team was very interested in hearing about my success. I then accompanied her back to the church, the two ladies smiled and nodded their heads, and there were then two of us who felt prepared to wait a while longer in the van!
Then my phone signaled a voice mail, which was from the resident that went on with the first van. The first van, packed as it was, was flagged down by the three translators about half way to the clinic, nowhere near where we expected them. They packed into the van with them and were at the clinic waiting for us! So off we went. We ate our power bars for lunch on the way at about 11:00, figuring that it wouldn’t look too good to arrive, work for an hour, and take a lunch break.
So our day started off slowly, but at least the van had AC and music!
I have noticed some trends in the clinic patients which I think are earthquake related. Many have gastritis symptom that began with the earthquake. I wrote about that already. Many also complain of insomnia, which is not at all surprising, especially in light of the frequent tremors that we have experienced at night since we have been here.
Many of the patients have a rash on their exposed arms and legs that also started after the earthquake. Some have scratched their skin open and have secondary infections. The rash does not look like insect bites, which would be more likely as the people spend their nights out of doors. I wonder if it is a reaction to the dust from the concrete buildings that collapsed that reacted with their sweat causing dermatitis.
I better understand now why it looks like there is construction work in progress all over. The piles of fine material next to piles of gravel and stone are the products of the sifting process that took place when collapsed buildings were dismantled and searched for human remains. There are many areas where blocks are neatly arranged or even stacked where they had once been part of a wall. It looks like some ancient excavation sites I have visited where only the outline of the structure remains.
The construction crew at the clinic is winding down its repair work. The clinic looks almost new! It is well stocked, and the patient volume is manageable for one physician. We relocated one of our residents and our Haitian American nurse to Quisqueya this evening, the school that has become the medical relief command center. They will join up with our surgery team. The Quisqueya leadership has a goal of functioning in this capacity until 85% of the medical facility capacity is restored in the country. Our efforts next week will be through the coordination of the folks at Quisqueya, as we seek to do the most good with the resources we have.
We may yet return to Lilavois at a future date, but for now leave it with a sense of accomplishment and a heavy heart for one of the communities that has a long way to go to return to a near normal life. One resident and I will return tomorrow to help see patients and finish up organizing the pharmacy and medical supplies.
More later!
Thursday Evening Feb 25
Today Dorinda (family practice resident) and I went to Lilavois clinic with the construction crew, which included Dorinda’s husband Jesse, a carpenter who has proved invaluable building shelves, desks and counters as well as repairing doors and other broken wood items. He has acquired Haitian apprentices that are learning quickly.
One of our two translators went with the construction guys to buy more material. Dorinda and the other translator began clinic along with a Haitian doctor. I sorted medical supplies and made order of the pharmacy using the newly built shelving units. There were dozens of boxes of mixed medical supplies and medications, some trash, but most very useable. Things in excess or not useable in Lilavois will be taken to Quisqueya to add to their supply tent.
Our trip home was later than usual, and darker than usual as rain clouds rolled in. We had a pretty good downpour which turns the limestone streets into slippery sheets. There is quite a hill to climb to the guest house. Both vans couldn’t find enough traction so we got out and pushed up the hill. We all had our showers for the evening! Actually when we returned, many of the guys went out in the rain with soap and finished their showers.
Because of the rain, we decided to postpone my departure for Qisqueya until the morning when the roads will hopefully be drier and the daylight will be helpful in navigating the ruts. I hope to get there early enough to join our surgery team before they depart for the hospital. Dorinda will return for one more day in the clinic at Lilavois, moving to Quisqueya in the evening, exchanging places with the four from the surgery team who will stay in the guest house with the construction crew, ready for an early departure on Saturday AM.
Time for bed!
Friday evening Feb 24
Where do I start! It was an overwhelming day participating in organized chaos at the CDTI hospital. I joined up with the surgery team this morning and became a wound care doctor. I changed dressings, cleaned wounds, drained abscesses, pulled orthopedic pins and prescribed antibiotics all day. I saw a few run of the mill surgical patients in the mix, and ended the day dealing with a toddler who put a piece of corn in her nose!
Many of the trauma patients had already been operated on for broken bones and crush injuries. Our plastic surgeons had performed some skin grafts and other procedures. They and the orthopedic surgeon from Minnesota were my resources, instructing me on how to care for their patients, giving me advice on other situations. French, German, Mexican and Canadian medical professionals were all working side by side in a tremendous cooperative effort. We received orthopedic and plastic surgery transfers from other facilities.
Two of the most notable patients were two ladies who had been buried alive, one for two days, the other for three. One already had an arm amputated and had multiple pressure wounds from lying covered with rubble. She is also likely to lose part of her foot, which appeared dead today. The wounds are not infected so we will watch her foot a while longer to determine what level we will need to amputate.
The other lady buried for three days had some of the deepest wounds I have ever seen over her hips. They were both draining pus. She also had lost control of one foot on the side of the deepest wound. She needed some of the high tech devices we have in the states, but don’t have available here in Haiti.
I did ask one of the many interpreters to buy some honey for wound care. I had good success in Honduras with using honey on chronic wounds. It sterilizes the wound by releasing hydrogen peroxide,, prevents bacterial growth, stimulates healing, reduces scarring, is inexpensive and almost universally available. Many of the patients coming in for wound care can be transitioned to outpatients. For the moment they are staying in the hospital tents in front of the hospital. I am beginning to instruct them in home wound care with Dakin’s solution made with bleach and water to was the wounds, which they can then dress with honey and toilet tissue.
Throughout the day, the nurses and our family practice resident asked me to see various patients in the ambulatory wound clinic, the acute care clinic, and in the hospital tents. The need has been so urgent for acute care, and the physicians in limited numbers, that there has been no time to make official rounds on patients in the hospital tents. They are only seen by physician if they are brought to wound clinic, or by special request. The nurses are doing a great job caring for them, and asking for help as needed. They asked me to make rounds with them today, but we never got to it. Maybe tomorrow.
The need is so great, and the day so energizing, though exhausting at the same time, the family medicine residents and I plan to keep working during the weekend. CDTI will be short staffed this weekend as many groups are leaving and new folks arrive Monday. Wounds need cared for, and I expect people will keep showing up at the hospital, short staffed or not!
There is much more to share, but I need to sleep!
Saturday AM Feb 27
After a good night’s sleep on an air mattress with the benefit of a fan to drown out the noise of the city, and after a very satisfying breakfast of oatmeal, served cold, appropriate for the climate, a wedge of pineapple, a banana and a cup of coffee, I am ready to start afresh!
I awoke in the night, my mind racing concerning what I had experienced yesterday and how it could have been more efficient. I will look again for my friend who purchased the honey to ask her to find some bleach, baking soda, a spray bottle and some measuring cups and spoons so I can make Dakin’s solution, an excellent wound dressing for infected wounds. We can also use it to sanitize the treatment tables and surfaces.
The food at Quisqueya is predictable, and very good! The breakfast is as I described. There is a choice between watermelon or pineapple. The evening meal is rice and beans drizzled with a very tasty sauce, a piece of chicken, lettuce, and a very spicy but delicious cole slaw that has you reaching for water! The rule is, “take what you want, but eat what you take.”
At the guest house, breakfast was typically white bread, sometimes a slice of mango, and usually some form of eggs or tuna. Tuna seems a very pragmatic choice for the situation. It is so versatile. We have had tuna puffs, tuna and noodles, plain tuna, and a tuna spread. With the lack of power it makes sense to see tuna here; easily shipped in, doesn’t need refrigeration, already in useable portions, and high in protein.
As out Quisqueya community comes alive this morning, I hear many languages being spoken, greetings exchanged, smiles all around. Last night was a bit noisy as people prepared to leave. There was some singing and dancing, with drums accompanying the music, beer and wine shared in moderation, tears and hugs as new friends parted; friendships forged in adversity and through common goals across culture, race, politics, religion, and age, things that would in other circumstances normally cause division and segregation.
Why does it take disaster to create unity?
Saturday evening Feb 27
We finished in the clinic a little early today at 4:30. My last patient was a relief worker from Atlanta with right lower quadrant abdominal pain; my specialty! He didn’t have appendicitis we are both happy to report!
Our family medicine residents, Krista and Dorinda worked in “triage” today seeing patients who walked into the clinic with various acute and chronic problems. There was a boy with sickle cell crisis, a common problem we are seeing, increasingly more people with diarrhea, and sexually transmitted diseases, including a man with both knee joints infected with gonorrhea.
Jesse, Dorinda’s husband, was transporting patients, a very difficult job, hauling gurneys and stretchers into nooks and crannies that were not intended for patients, let alone bulky gurneys. All the patients were hurting, many with external fixaters, large metal screws imbedded into their bones at right angles, attached to each other like scaffolding to hold the bones in place for healing. These added weight, bulk and stiffness of extremities to the already difficult transfer process.
Today I had the great pleasure of working with a group of Mexican nurses and doctors from their marine corp. They are stationed on a hospital ship in the bay, flying in by helicopter each morning. They adopted me into their group, and assigned one of their nurses to help me in wound care. They had Spanish speaking interpreters which I also utilized to communicate with the patients.
In the midst of seeing chronic wound patients, in rolled a wheelchair pushed by someone yelling “Emergency, emergency!” The patient was a priest from Costa Rica who had been shot in the leg while leaving a bank. He had blood stained pants and someone had placed a tourniquet on his thigh with a piece of PVC pipe. The Mexican nurses quickly stated an IV while I cut of his pants. Fortunately he had a clean small caliber injury with entrance and exit wounds. The pulses in his foot were intact, as was his sensation. I released the tourniquet slowly; no bleeding. The Mexican orthopedic surgeon quickly checked the leg, and we agreed there did not seem to be any serious injury. The priest had a fellow worker who is a nurse. He preferred to leave and have his friend watch him for any changes to occur than to stay in one of our overcrowded tents.
In addition to using honey on wounds, that my new friend, Rosaline, a Haitian American translator with family in Port au Prince, I asked her to again visit the supermarket to buy me measuring cups, a spray bottle, Clorox bleach and baking soda to mix up Dakin’s solution, a good wound antiseptic to pack chronically infected wounds. Rosaline bought some spray window cleaner, which I dumped and rinsed, filling the bottle with Dakin's both to spray on patient wounds and on the tables between patients. By the end of the day, the Mexicans were using Dakin’s solution and honey on most of their patients too!
Today I saw many of the same patients from yesterday for their daily dressing changes. It was encouraging to see so many of the wounds looking healthier. Most of the patients smiled as they recognized me from yesterday. A few met me with fear, remembering the many painful dressing changes they have suffered through. I was happy to see that none of the patients that had honey on their dressings had attracted ants! A couple of patients had healed wounds and were ready to be discharged to home(?). Many don’t have homes to return too, a difficult problem. Some of the children in the hospital also lost their parents; an even more difficult problem!
That’s it for tonight! Time for our regular 7:30 meeting to get our assignments for tomorrow!
Monday PM, March 1
Clinic is winding down at CDTI. Joanne, the nurse practitioner, Dorinda, the family medicine resident, her husband Jesse and I were part of a group of nearly 30 people at CDTI from Quisqueya, in additional to staff from other groups of relief workers.
After we loaded the bus this morning, we found out it wouldn’t start. This led to quite an international discussion on what to do. A mechanic was called. It was suggested to push start the bus. The driver called the owner who didn’t want it pushed started. He wanted a mechanic to evaluate it.
We then sent 8 of the most essential people on ahead in a pickup, and prepared to send another 14 in our rented van with the slow fuel leak. By the time we loaded the van, a blown fuse in the bus was changed, so we returned to the van and were on our way.
The crowd of patients waiting for us at CDTI was the biggest I have seen yet. Mondays everywhere seem to be the busiest! About half our relief workers were new, so it was a slow start requiring time for orientation and becaming familiar with the system. The Mexican marines were already busy in the wound clinic. I was planning to join them, but was called to the ambulatory wound clinic to check a skin graft. From there I was asked to see another patient who I had seen last week and had asked him to return for an anal exam under anesthesia. I thought he may have an anal fissure.
Then my phone rang. It was Greg, one of the Life Flight nurses, who was traveling with Bev and Jeff from Life Flight, and Dr. Brian, on their way to a clinic. They were evidently lost. The driver took them to another clinic that was not expecting them. I went on a search for the director of the relief effort at CDTI, Justine, a D.O. orthopedic trauma surgeon who left her practice in Colorado Springs to come to Haiti after the earthquake. She quickly became the driving force in turning CDTI into a functioning post earthquake hospital.
When I finally found her, Greg had called back to ask what to do. Justine had a Haitian cell phone, which I used to call the logistics folks at Quisqueya who then called the driver of the van our guys were in. A short time later I received a text that they had reached their destination!
I then headed for the CDTI computer to activate my international plan on my ATT iPhone. Up to Feb 28, service to relief workers in Haiti was free. It now is only $19.99 a month plus a reduced rate for texts and calls for relief workers. I had tried to activate the plan before I left the States, but the person on the phone said I needed to call on March 1 before I made any other calls. I could not get through to ATT with the numbers she gave me. Worried that my phone bill would be astronomical, it became a priority to activate the plan. Finally, with a very slow Internet connection, I was able to get to the right web page and check the right box.
Meanwhile, my patient with the pain in the behind was waiting to see if a Haitian anesthesia provider would show up. While finishing up on the computer, I heard a very strong voice say, “Hi, my name is Larry. Which way is the OR? I am an anesthesiologist sent her to help in the surgery.“ I told him that I had a minor case for him, which he was happy to do. Larry is a no nonsense very pragmatic
anesthesiologist with a fair bit of international experience with Mercy Ships. I told him the scant information I had on the patient, expecting him to want more. His response was, “Show me the OR and bring the patient in!” Our entire charting for the whole process was on a scrap of paper.
As soon as I finished and walked out of the OR I ran into a nurse who was looking for me to see a guy with an abscess, a large pocket of pus, under his arm. As we were leaving the surgical department, we were almost run over by a group pushing carts loaded with suitcases and duffle bags. The announced “We are an orthopedic team here to operate,” which was a welcome surprise to everyone. I asked if they brought an anesthesia provider. They did not, but Larry was available! I gave the orthopedic surgeon and his PA a quick tour, introduced them to the Mexican orthopedic surgeon who informed him of some cases that needed done. The Mexicans were afraid to work in the hospital beyond the first floor, so the cases had not been done. The other limiting factor was that Xray was not functioning over the last few days.
Very quickly the orthopedic surgeon surveyed the injuries, and began wheeling people up to surgery to use the portable C arm Xray unit to evaluate fractures. This led to a parade of gurneys and wheelchairs up the ramp three floors. Many surgical cases were quickly identified. By the time I finished draining the abscess, the orthopod was ready with his first case.
It was about 1:00 by this time, and the Mexicans were leaving. I then took over the wound clinic finishing with the patients remaining, two who needed sedation to change their bandages. Larry ran down the three floors between cases to give sedation for one patient, and gave me instructions on what to do for the other, which I did assist by a nurse, much as I had done many times in Honduras.
Things are now slowing down in the clinics. Tomorrow, if I can squeeze into the now growing OR schedule, I have a hernia to repair, and a circumcision to do on a child whose foreskin has grown so tight it is restricting his urination.
Such pleasant thought to end the day!
Tuesday AM, March 2
As our team members reassembled for the evening meal, we exchanged stories. The stories highlighted a couple of things: 1) people are pretty much the same wherever you go, 2) there remains a fair bit of disorganization in Haiti and the relief effort.
A couple of our groups went to man clinics. Most of the people presenting were not really “ill” but were presenting for headaches, backaches, etc, the usual “aches and pains” of life, that we in the States have learned to deal with by taking whatever we have in our medicine cabinet. Unfortunately, for many of these patients, their medicine cabinet is buried in rubble, and the neighborhood pharmacy is closed due to damage, or lack of stock, or lack of money in the community to make it profitable. There is an underlying anxiety that runs through the population that has experienced something so dreadful, so unexpected, so out of their control, leaving their lives forever changed, minus many of the foundations of their lives; family, friends, home, neighborhood, that seemed indestructible before. It is no wonder they flock to the clinics run by foreigners, hoping that maybe somehow there is something that they can take, a bandage to a wound, that will make it all better!
For us as North American relief workers, we often have our preconceived ideas of charging in and saving the day through the dramatic, the things that make the news, hauling the living from the rubble, patching the acutely injured bodies, performing the life saving operations. But as for much of life, the mundane rules! People still have headaches and back aches, and diabetes, hypertension, and common colds; and they have a vast emptiness that they can’t express, nor find the cure for; a deep seated anxiety that they can’t find relief of because no one can promise them with sufficient certainly that things will indeed be all right again.
Despite the hugeeffort that is underway that appears to be remarkably well organized, yet at times it appears chaotic. Multiple organizations are involved, some duplicating efforts, other things falling through the cracks; two teams from different organizations showing up to serve the same community, as happened to one of our groups yesterday, while other communities remain unserved; volunteer drivers losing their way, going to the wrong place, or getting times mixed up, since everyday is different, and the language they speak is different from that of the person giving them directions. Supplies keep arriving swamping the storage capacity; needed items remain buried somewhere in a box or container, while an excess of less useful items fill the limited shelving space.
The relief effort is big, is accomplishing much, yet leaves something to be desired in an ideal situation for which one could plan. But who could really plan for something like this, accounting for all the details and variables? So we do our best, try to be flexible, deal with the frustrations, and help those who are in need the best way we can under the circumstances we face.
Thursday AM March 4: What’s Next?
As I awoke to the sound of rain this morning, it reminds me that change is around the corner. There have been evening showers, but usually by morning the sky is clear. We have heard the worried predictions about rainy season, and the additional hardship it will bring to the tent cities, adding to sanitation problems and hindering reconstruction.
As I reflect on the future of medical relief, having a long list of medical providers who too want to be involved, I see the direction as two fold. First, the urgent needs of the immediate post earthquake are fading into the need for physical and occupational therapy, plastic and reconstructive therapy, orthotics and prosthetics, continuing orthopedics to handle the fracture non-unions and osteomyelitis (bone infection) cases.
I also see the ongoing daily medical needs. We are seeing trauma patients; motor vehicle accidents, gun shots, construction (demolition) injuries. There has been a plea for pediatricians to help handle the neonatal problems and premature babies, as well as the usual childhood diseases that are becoming exacerbated by the crowding, lack of food, and lack of sanitation. Primary care teams to the tent cities are going out and seeing long lines of people for the “mundane” complaints common to a family practice and urgent care facility in the States. We have already mentioned the very frequent post earthquake complaints of gastritis, rash, insomnia and palpitations, not to mention the always frequent headaches, back aches and generalized body aches. There is also malaria, but many doctors unfamiliar with the presentation are likely missing the diagnosis. Some facilities are using rapid test kits that are revealing the illness and increasing the providers understanding of the disease.
So, as OUCOM continues its relief effort, what should be done? I think people need to be sent to address the needs mentioned above, with expectations to match. We should be moving into a role of filling specific needs rather than sending down anyone who cares to go. We can coordinate our efforts with the folks at Quisqueya and the University of Miami tent hospital near the airport, to help them continue their work efficiently. We may want to “adopt” a community, such as Lilavois, and support the reconstruction and development of their hospital, bringing their operating room into function where we could send future surgical teams.
Supplies are stacked everywhere we look! There are unopened boxes and containers with yet unknown caches of medical materials, some much needed, some probably destined for the dump. For at least the near future, relief workers probably don’t need to bring boxes and bags of supplies, unless there is something very specific to their job, and / or there has been a request for a particular item.
As the Port au Prince airport returns to normal function, relief workers can fly directly into Haiti. Those who are bringing bags are not receiving them for a few days since everyone is trying to bring extra things to Haiti to help. The planes filled to capacity are forced to leave some luggage behind. If a relief worker can limit themselves to their carryon and personal bag (purse, backpack) he / she can arrive with all belongings and more quickly proceed through customs. If arranged appropriately on line through Quisqueya at http://relief.quisqueya.org, someone will pick you up at the airport. Flying on days other than weekends may increase the flight availability since most teams seem to be traveling on weekends.
As Joanne and I return, we will be meeting with Dr. Gillian Ice and others to plan out our future role in the Haiti relief effort.
More to come!
Friday AM, March 5
As the residents and I have talked, the last few days for us at CDTI have felt a bit light nights on call as an intern or early resident, feeling like a ping pong ball, putting out one fire after another. Yesterday was a good example of such a day for me.
Since the afternoon before I went to Community Hospital with a transfer patient I missed a dressing change. One of the patients who had been buried for three days in rubble, and developed severe pressure sores that will eventually need plastic surgery would not let the Mexican team change her dressings. She said they were too rough. So she refused the dressing change on Wednesday. First thing in the morning we moved her into the emergency room for her dressing change before the Mexicans arrived. Her wounds are doing well, but still harbor some infection that needs resolved before she has surgery. We made arrangements to transfer her to Community Hospital where a group of American plastic surgeons has set up a base of operations for 6 months. The patient seemed reluctant to go. She asked all kinds of questions, and then finally asked if she would be sleeping in a tent there. I told her, “no”, which caused a fair bit of anxiety. She is afraid to sleep in a cement block building after what she has been through. I assured her that the building looked very sound when I saw it. She reluctant agreed to go.
Then I walked up the three story ramp, the first of probably 20 trips I would make for the day, to repair a hernia on the Haitian orderly that had watched me do the same operation a couple of days earlier. I had started to give the anesthesia myself, when in popped two of the Mexican nurses who offered to help, one managing the anesthesia, and another circulating. Before the case was done, the Mexican anesthesiologist was also present helping! We had a truly international experience in the OR, playing the music of Danilo Montero, one of my favorite Hispanic artists, in the background.
With help, we rolled the patient down the ramp to the recovery area and found his wife. I Talked with her via an interpreter, then went to the pharmacy and picked out some medication for the patient to take home with him.
At this time, one of the nurses brought me a note from another facility that a patient had carried in. It was a referral for a breast lump. She even had an ultrasound report. I went on a hunt for a private place to examine the patient and hung a curtain. Then I found a female translator and examined the patient, who indeed did need surgery. I went up the ramp to schedule the case, and returned with the information.
Then another doctor asked me to see another patient who had a breast abscess, a pocket of pus beneath the surface. I started her on antibiotics and scheduled her for surgery. She was worried about things and asked if she would be able to have more children. I assured her this would not be a limiting factor. “Good!” she said. Her two children had died in the earthquake, and she had hopes of another family!
Then I was told about two more patients who had breast problems! One was a family medicine problem, but the other sounded like a surgical problem. This patient had what appeared to possibly be an aggressive form of breast cancer that involves the skin. She needed a biopsy. As we talked, she mentioned that she had not had a period in two months, since she had an abortion. On examination, she appeared to yet be pregnant, but there was no way to be sure the baby was alive. I took her to ultrasound, talked with the Haitian radiology resident, and left the patient in line to have an ultrasound of both the breast and the pelvis.
I was then off to climb the ramp to surgery again. The orthopedic surgeons were running behind, and I had offered to help with some of their minor cases, and with anesthesia. There was one young patient who had a broken forearm with a pin in his ulna, one bone of the forearm and a plate with screws on his radius, the other bone. He had developed swelling of the entire hand which was suspected to be an infection. I was to pull the pin, open the wound, clean out the pus, and remove the plate. I gave the patient two injections of Ketamine, an anesthetic akin to LSD which dissociates the mind from the body. I removed the pin with a good tug, and then turned my attention to the swollen wrist that seemed to be pulsating. I used a needle to withdraw fluid from the swollen area, which was blood, not pus. I talked with one of the orthopods in the next room who “broke scrub” to join me. He placed a tourniquet on the patients arm and reopened the wound to find the swelling caused by blood. After rinsing out the clots, he cautiously let down the tourniquet and what we feared was present, a hole in the radial artery; probably a weakened area in the artery from damage from the fracture or from the surgery, had broken down and had formed an aneurysm. The orthopod quickly moved aside and said that this was more my specialty.
I checked the artery for back bleeding from the ulnar artery, which would mean that the other of the two arteries feeding the hand was intact, and I could simply tie off the leaking artery; but no such luck! This was the only viableblood supply to the hand! We found some fine vascular suture, about the diameter of spider web. I had to take off my glasses and place my face a few inches from the wound to see well, and was able to suture the hole in the artery. It looked like it would do well as long as the artery didn’t break down further. I closed the wound, transported the patient downstairs, and headed for ultrasound.
The abortion had not worked and the patient had a healthy appearing 17 week pregnancy! The radiologist had convinced her to keep the baby since it was too big for a simple abortion. I wheeled her upstairs for removal of a little piece of the abnormal skin of the breast with a local anesthetic. I will take the specimen to my pathologist in the states, since there is no reliable way to get pathology results in Haiti right now.
On my return downstairs, I was asked to look at a 12 y/o who had an undescended testicle. It could be seen on the lower abdomen instead of in the scrotum. I scheduled him for surgery to remove the testicle, which would not be functional and would have an increased risk of cancer, and to repair the associated hernia.
After a quick late lunch, I did another dressing change, then headed upstairs to give anesthesia for another orthopedic case. After transferring him downstairs, it was about 5:30 and time to call it another day at CDTI!
Our last full day in Haiti appropriately began and ended in rain. The gray sky mingled its drops with our tears as we said good bye to new friends; Haitian, American, and from around the world; patients and coworkers. Unlike so many trips I have been on in the past where there is sadness in saying good bye, there is usually a sense of celebration over a job completed. But our hearts are heavy as we leave a job undone; so many loose ends, so many sick missing arms and legs, open wounds, scarred souls, their country in ruins. It seem so inappropriate to drive away to Santo Domingo, to enjoy a nice meal in a restaurant, a hot shower, a real bed, an air conditioned room, and electricity at will.
Never will we be able to think of Haiti as we did before. I knew it was the poorest country in the hemisphere, ranked in the last four with Nicaragua, Bolivia and Honduras. In my mind I compared Haiti to Honduras, where I lived with my family for seven years, but not any more. In the past as I heard of hurricanes bearing down on Haiti, I thought, “Too bad!” This hurricane season I will plead, “GOD, PLEASE SPARE HAITI!” as I think of the hundreds of thousands, maybe millions, who now call a tarp, a lean to or a tent their home. Having lost their supposedly solid home in an earthquake, their frail dwellings will so easily fall prey to a tropical wind of very minimal force. I can see it in my mind, and it brings tears to my eyes.
So let us not forget Haiti! The job is not done. The work is becoming more specialized, more specific. We will continue to help as we are enabled, to send people and supplies, to make useful contacts, to help Haiti heal, for we have been called into the healing profession, and healing we must do!
What next in Haiti?
As we have returned to the States, people ask, “How was the trip?” They are genuinely interested, and want an informative answer, yet I struggle with what to say!
To answer, “It was good!” seems very inadequate, and inappropriate. Though there were aspects of the trip that were “good”, this just doesn’t feel like the right thing to say.
To say it was fulfilling, likewise is not accurate. I have returned with a big hole in my soul, aching for the people who continue to suffer, feeling like we didn’t do enough, just scratching the surface of a problem that is too big to even understand, let alone begin to solve.
Was our trip successful? Yes, in that we did some good for people in need; we left with a better sense of the problems in Haiti; we formed many relationships through adversity and cooperation. Unlike other trips in which I have participated, our team lacked some of the cohesiveness due to being scattered in different locations to serve, rather than working side by side. Also unlike other teams, we did not have a defined end point, a defined set of tasks to complete. Instead we jumped into an atmosphere of “organized chaos”, helped as best we could, and left the situation hopefully slightly improved, but without much sense of completion.
So the need goes on! How can you help? How can the next wave of volunteers participate?
There are two good avenues of service we have identified. At this point, OUCOM will not be sponsoring another team, but individuals or groups that wish to serve together can go directly with the two organizations described below. Our team stayed as Quisqueya, where we were safe, and well provided for. On our last day in Haiti, we visited the University of Miami facility, which was very impressive.
1)
The University of Miami
has set up a “medical center” at the airport in Port au Prince. They are concentrating on internal medicine and pediatric needs, as well as trauma. They have a pediatric ICU, including neonatal care, and a pediatric occupational / physical therapy department.
Volunteers can sign up at: http://www.med.miami.edu/haiti-relief/#volunteer. Volunteers need to get to Miami to catch a flight on Saturday or Monday to Haiti. Volunteers serve for at least a week. Donations are accepted, but there is currently no charge to participate. This may change. Volunteers will stay in a large dormitory tent, and be supplied one meal a day. They need to bring power bars, etc for the rest of their meals. This is a “medical center” in which nursing and “in patient” type care is the focus, but there are ambulatory patients as well. You will likely spend your entire time at the center.
2)
Quisqueya
is a Christian school in Port au Prince that has become a center of medical relief for the area, coordinating volunteers to over 20 different locations in the area. Volunteers can sign up at: http://quisqueya.org/qcsrelief/how-can-i-help/group-information/. Quisqueya will coordinate transport from the airport to their facility. You will need to pay for your airfare. Quisqueya is also not charging for their services, but is suggesting a $50 / day donation to help cover their costs. Each evening at 7:30 the Quisqueya staff holds a planning meeting with team leaders and individuals, outlining the needs in the area, which range from staffing hospitals with surgery and anesthesia providers to tent city clinics. Residents will be sent out with appropriate supervision. Quisqueya provides all transportation, breakfast, an evening meal, and a place to sleep on campus.
Quisqueya is an Evangelical Christian organization, which is evident in their environment and work ethic. They are cooperating and coordinating efforts with a number of humanitarian organizations and the U.S. military. There are no requirements to observe or participate in spiritual activities. They open their evening planning session with prayer. I believe non Christians would be comfortable with the environment.
We would suggest you consider travel insurance. Possible providers include: http://www.travelguard.com/ , http://www.hthworldwide.com/, and http://www.internationalsos.com/en/.
Please contact us if you have any questions! We would love to see others involved!