Sunday, February 28, 2010

Observations made on the road to and from Gressier, 2/8/2010 


We drive 45 minutes each way, from the hospital in Port-au-Prince to Gressier. It has been an eye-opening experience, since prior to this I have only been between the hospital and hotel, a 5-minute drive.

* Everyone is sleeping outside. Everyone. Those who have their homes flattened, those whose homes have cracks, and all others. Everyone is afraid to sleep or work in any of the buildings until an official government engineer inspects a building and finds it safe to re-inhabit. This affects Port-Au-Prince and all the towns we passed on the way to Gressier. I suspect it affects the third of the country most heavily hit by the earthquake.

* Sleeping outside means that people are gathered together in tents to sleep. Tents are mostly sticks lashed together with sheets or towels or shirts stretched across. Sometimes, cardboard or tin or other materials are added to the mix. The tents are in large areas, such as parks or open spaces, all packed together. They are also pitched in small areas, such as the median strip of highways. Daily life goes on in front and within these tent areas — people wash their clothes and their children, prepare their meals and eat. There is little privacy, a luxury here.

* There seem to be increasing numbers of sturdy tents from NGOs. Shelterbox provides beautiful tents for families, and I am seeing more and more of them in some parts of Port-au-Prince. That is a great thing because many fear the rainy season and the difficulties it will cause for people living in flimsy dirt-floor tents.

* The condition of the roads, never very stellar in Haiti, is getting worse each day. As we drive to Gressier, our driver and translator exclaim periodically when we encounter a new split or depression in the road, probably caused by the frequent aftershocks. Says translator Denise, “the earthquake crashed the road more, and cut it worse.”

* An increasing problem: trash. Trash pick-up seems to be on hold as any large trucks and resources are dealing with the bigger issue of earthquake rubble. Meanwhile, people have nowhere to put the mounds of trash — plastic bottles, cartons, wrappers, etc. Haitians tend to use and reuse whatever they can, so there is much less trash per person here than in the U.S., but what is here is simply adding up and combining with the dirty water in the streets. We saw one whole street with a continuous mound of trash 6 feet wide and 4 feet high. People climbed over it to get to the other side of the street and children played along the edge — a public health problem brewing. This also makes driving difficult, as you have to weave around the trash piles, as well as slow down for the new cracks in the road and avoid other rubble and wires. (There was one tangle of wires hanging across a street we routinely travel. One day last week, it had dipped so low that there was a spark when our bus went under it and didn’t quite clear. The next day the wires were removed, thank goodness.)

* Clean-up crews of citizens have taken to the street — men and women, young and old. We saw hundreds with blue T-shirts, armed with shovels and brooms and wearing masks to protect their lungs from the thick dust that is in the air. By the end of the day, there was a visible improvement in the look of some neighborhoods. These crews are dealing with small jobs along the side of the road and walkways. These folks are doing all the work by hand. Bigger machinery must come to remove the huge concrete slabs and chunks of concrete bricks from destroyed buildings.

* Crushed buildings seem fair game for scavengers. In these circumstances, people are struggling to survive, and they are willing to dig through rubble to pick up pieces of wire, wood, and other items that they will reuse.

* Food distribution is a tricky business. We pass one area where the UN and U.S. soldiers stand a few feet apart in a long line to provide security as the distribution occurs. Some programs are giving the food to the women to bring home to families. Once, there was a brewing protest — it seemed people didn’t like the method of distribution.

* Generally, a sort of daily life has somewhat returned. People are seen walking along the street, moving their wares to sell, bringing home food, children playing, etc. The streets we have seen are mostly quiet. There is no sense of violence or lack of safety that I have observed. One exception is when a foreigner sticks a camera out the window to snap a photo of people bathing or the tent camps, etc. Then usually one or two angry people yell in protest — understandable.

Dr. Beth Sloand, Johns Hopkins University School of Nursing




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Still smiling after moving around on a broken femur


This beautiful young woman was seen in the ED tent at University Hospital for hip pain, three weeks after the earthquake.

She had been seen other places twice before and given pain medications. With the notes on the WHO paperwork we could follow her care and with a brief assessment we decided that she most likely had some type of femur/NOF fracture. This was confirmed by x-ray and with the liaison that we had with the team on the comfort, International Medical Corps Dr. Brian Crawford coordinated her transfer to the USS Comfort.

I was impressed by the ability of her to still smile after moving around on a broken femur----ouch. She was also the last patient that I transferred to the Comfort.

Feeding orphaned infants


Here I'm examining a 2-month-old girl brought to an International Medical Corps mobile clinic in Petionville.

The infant suffered from malnutrition as her father struggled to feed her in the absence of the child’s mother who perished in the earthquake 2 weeks prior.

Mashing up whatever food he could find to feed the newborn infant, the father looked to International Medical Corps to assist him in feeding his child. Haitian nurses assisting in the mobile clinic identified a local breastfeeding mother who volunteered to help feed the child, and both parties were managed by the nearby DMAT clinic to coordinate a wet-nursing schedule.

Doctor Jennifer Schwieger

"Je aider..."


This is the same girl that I sent to the USS Comfort on one of my last days in the ED tents and was very impressed with the local people's willingness to help. Her mother was also injured and could not help her get around and she needed to get to the restroom.

She wanted to walk but we insisted that was a bad idea. “Je aider” came from two gentlemen who were standing in the tent and they carried her in a chair to the restroom and then back. Yet another testament to the help that was being provided by so many.

Even with the progress we've made, mixed feelings about leaving Haiti


January 25…
At the end of our 9th full day working at the University Hospital in Haiti, we have made remarkable progress in a little more than a week, and a hospital has emerged.

Our tent E.R. saw nearly 300 patients today, and we are preparing to see more than 500 tomorrow, in what are essentially two rooms. To keep the place running, we are electricians, masons and plumbers, as well as doctors.

I find myself beginning to lose my endurance. Everyone is getting tired…I can see it in the faces of all the people with whom I work from every country and whom I have come to admire a great deal. Every day brings new crises of capacity, supplies, sudden patient influx or something else. We have been with these people more than a week and have come to know them, so deaths and disfigurements affect us a lot.

The media frenzy is beginning to die down. Four days ago, you could not turn without a camera or reporter being there to document the activity. If that brings resources to Haiti, I am all for it. I have been disappointed, however, in some of the inuendos. Let me tell you the truth – everyone is working incredibly hard, getting along, cooperating, and there are very few controversies. We have the operating rooms coordinated, a way to care for orphans, and a small blood bank. Our big problem is space, but USAID [United States Agency for International Development] just brought us three big tents tonight, which is a huge relief.

I visited many of the patients I know this afternoon, just to touch their hands, wipe their foreheads, and encourage them. They are all missing a leg, an arm, and many relatives. Think about how life has changed for them and about what you might do to make it a bit better for them. Please pick a relief organization and make a small donation. It truly makes a difference.

January 26…
On the 10th full day in Haiti, we find ourselves at the transition point where we must carry out our duties, but begin to transfer responsibility to the persons who will assume our roles upon our departure.

Some of our team has begun to “hit the wall” physically and emotionally. I am fine emotionally, but these old muscles are aching for sure. However, every time I walk past a young Haitian child who has lost a limb, yet still smiles and tries to give me a wave, I am energized. It will be very difficult to leave, but I know that within a few days, we must get our batteries recharged.


The hospital complex is really taking shape now. The tents are wall-to-wall and all filled with patients. We have arranged for electricity and sanitation. We have oxygen bottles and new stretchers. Yet, we are still missing critical sterilization equipment for surgical instruments, modes of transportation, phones, and sufficient supplies to call this a complete medical operation.

Some of my new friends from other NGOs have begun to rotate out, and I miss them already. We have become close “under fire,” in a way that is not possible in any other venue. We would trust each other with our lives.

Three of us shared a common experience today, individually, as we walked down the road past the crushed nursing school and towards the Swiss surgery tent compound. We all noticed for the first time beautiful flowering bougainvillea that had been completely overlooked when we marched, heads down, along what was only a week ago a thoroughfare of death. We smelled the cooking from the street, and walked past tents of injured persons singing, trying to be happy, attempting to begin to get back to normal. They are so brave and so deserving of all that we can give them.

Our group has befriended the young 5-year-old boy who was pulled from the rubble after a week. He comes to visit us, and clings to the nurse who was most attentive to him during his resuscitation. His parents are lost now and he is an orphan. He is like thousands of children in Haiti now. The orphanages are filling, and reconstruction cannot occur fast enough to avoid enormous tent cities.

January 27…
We’ve been here working at the University Hospital in Port-au-Prince for nearly two full weeks, and it is shaping up. The care being delivered is remarkable given the circumstances since the earthquake.


There are two operating rooms running 4 beds each, a tented medical unit for our sickest patients, a fully stocked pharmacy, an increasing laboratory testing capability, and more tents. Still, this is not a hospital as we have become accustomed to in the US. It is a medical facility under tents, and the conditions are not sterile. While the situation is improving, and we have optimism that it will continue to improve, for the patients who have suffered bad injuries, they are certainly not yet all out of the woods.

I find myself going back to visit a few patients, like the young woman professional dancer who lost her leg. She was returned to the OR today for a revision of her stump, so was postoperative and asleep when I saw her. In the crowded tent, she was covered with flies, so I sat by her for a while and fanned them away with a small notebook. In another tent, I watched a mother bathe an emaciated infant. The baby will not make it through the next two days. One tent over, a woman shouted out in pain during childbirth.

The garbage is being picked up and we should have upright portable bathrooms tomorrow. That is a triumph towards which I have struggled for days. Once again, the U.S. military showed its compassion and coordination when nearly 50 patients were evacuated to more advanced care.


Yesterday the generator went out for many hours, so we could not run the O.R., or so I thought. A team of resourceful surgeons wore their headlamps and made it through some of their cases.

Tomorrow we will finalize coordination of sanitation, electrical lines, tent placement, number of physicians needed through the next two weeks, and how to accelerate the return of Haitian physicians and nurses. There is much work to be done.

We got word today that we may be going home soon. I have mixed feelings about that. It will be difficult to leave, but all signs point to it approaching the right time. Emotionally, I am OK, but my legs are a bit wobbly. I wake up as tired as I was when I went to sleep. The people here deserve fresh legs.

January 28…
We found out today that we are going to ship out tomorrow. My feelings are certainly mixed. There is an incredible amount of work to be done here – we have only contributed to the first wave of what is necessary. I cannot remember the details of much of what we did the first three days, when we were functioning on hyper-drive in a battlefield setting. My recollections become detailed after the third day, when we were able to see only four or five patients at a time, and we stopped triaging amputees to the operating room.

Teams of non-Haitian surgeons have left to go home, because the operations to be performed now are largely orthopedic and plastic surgery, as well as specialty cases. Sadly, there are scores of patients with spinal fractures who are paralyzed, and little can be done for them this far out from the initial injury. Children continue to reach out to us. I had a small child who is a triple amputee offer me his cracker with his remaining hand. One can only pray that the memories he carries of this tragedy are erased swiftly, that he is assisted in his rehabilitation, and that his life improves. All of these will, of course, be hard to achieve.

I visited one of my favorite patients, the young woman who danced ballet professionally before she lost her leg below the knee. She had a revision of her stump yesterday, so she was asleep, recovering from anesthesia, when I saw her. Today, she was bright and alert, and gave me a big smile when I walked to the side of her stretcher bed within a very hot tent. She motioned me to come closer, and we exchanged contact information. I will do what I can to stay in touch with her.


Many of our interpreters are living outside in enormous congregations of people in parks. I gave my tent to one of these persons and am distributing everything that might be useful to victims of the earthquake and to medical persons who have just arrived to take over from those leaving to rest or return home. There are plenty of medical supplies – the Haitian people need shelter, food, and water. Soon, they must begin to rebuild and take what was a feeble economy and turn it into something. This will be no small undertaking.

I am so proud of my Stanford colleagues and all the other doctors present in the compound who have worked tirelessly for the past two weeks. The teams from California, New Hampshire, Massachusetts, New York, Switzerland, Norway, Canada, Spain, Taiwan and many other locations all pulled together in a model of collaborative behavior.


It became time today for me to hand over the reins to Dr. Solomon Kuah, who will assume my role as the medical coordinator of the NGO activity. I said goodbye to many persons with whom I have become close under the most challenging circumstances. These are wonderful people. In a meeting of the leadership present, I told them that I have never been so proud to be among such an incredible collection of talent and dedication. Then I allowed myself to be infused with 9 liters of IV fluid so that I could get vertical and walk out under my own power.

Dr. Paul Auerbach
Photos by Margaret Aguirre

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Report from the mobile clinic at Gressier 2/10/2010 


Gressier has a public health clinic that was functioning before the earthquake. A Haitian nurse staffed the clinic, offering well child, prenatal, and sick care to the community. When the earthquake hit, the clinic stopped functioning and people had nowhere to go for acute or chronic health care. International Medical Corps has stepped in to help bring health care to this and other communities.

International Medical Corps is providing staff and support at the University Hospital ER and some inpatient units, and has extended staff and support to several communities in Port-au-Prince and the surrounding areas.

Staff and Setting
The Gressier clinic has a staff of 2 Haitian physicians, 3 Haitian nurses, 2 Haitian nursing students, and 2 other staff who register patients and assist in various ways. In addition, 2 of us from International Medical Corps, Dr. Joel from Chicago and myself, supplement the staffing.
We bring 6 big boxes of medicines, supplies, and equipment with us each day, since there is no place to keep items secure during the night. The building is not secure at this point. We would like to work inside but Haitians are very worried about the stability of the building so we are waiting for it to be evaluated by Haitian engineers. Meanwhile, we see patients outside under a couple of trees, moving every couple of hours as the sun moves in the sky. We all try to avoid being in the direct sun, especially me.

Patient mix and diagnoses
Adults and children walk in from the surrounding area. I have seen a 6-day-old baby, another baby born the day of the earthquake, many infants and young children, their parents and a few elderly.

We see 200 to 300 patients per day. The nurses and Dr. Joel spend the first 2 or 3 hours doing wound care. There are still many people who have huge wounds from earthquake injuries, some post infection, some look like healing burns. A few of the children cry in pain as their dressings are removed and wounds are dressed. The nurses hang gauze and Lactated Ringers from the tree for the wound care. The patients lie on a table or sit in a straw seat chair. It is quite a production.

Besides wound care, the patients come to us with mostly general primary care issues, such as fever, headaches, abdominal diarrhea, hypertension, fatigue and shortness of breath, aches and pains. We've also seen some new injuries, as people are now trying to clean areas, build better tent dwellings, etc. So we have had new lacerations to suture, as well as the old.

Some of our most frequent diagnoses are severe anemia, intestinal worms, insomnia (not surprising given the sleeping conditions and the facts of life this past month), tinea capitus, acute gastroenteritis, vaginal candidiasis, impetigo, and acid indigestion. We have also confirmed several patients with malaria, some children with acute pneumonia, and referred some others with TB and suspected HIV.

People also come to us with more random issues. A 35-year-old man came with a limp that he said began with the earthquake. We sent him for an X-ray, which showed Legg Perthes disease that he likely has had for years. No doubt he feels the limp more now since the earthquake but it is clearly not a new problem.

Parents brought a 2-year-old in who has a colostomy because he was born without an anal opening. They would like us to operate to fix it all. Another mother brought a 3-year-old who does not walk or talk. She requested some surgery or medicine to cure this developmental delay. I had to explain the hard facts about our limitations, and give them encouragement to involve the child in daily life as much as possible. When they see a clinic with foreigner staff, people sometimes think that miracles can happen. Unfortunately, that is often not true.

So acute post-earthquake conditions with broken bones and severe injuries has evolved into primary care plus continued care of the old injuries. One man came in with arm pain that he has had since the earthquake. His upper arm was out of alignment. We referred him for an x-ray, suspecting that his humerus had broken when his house fell on him but without care it has healed poorly. It is possible that an orthopedic surgeon at the hospital will be able to repair it to be more functional.

Breastfeeding
I have counseled many mothers to continue breastfeeding their babies. Several have told us that they believe their milk is bad since the earthquake. Now we have infants suffering from diarrhea, as they are being fed foods and drink other than breast milk. With the difficulty finding clean water in Haiti, and the near impossible chance of mixing formula or dry milk powder in a clean bottle with clean water, breastfeeding is truly life saving for babies. So we educate and encourage. "Breast milk is the best food for your baby." "Breastfeed to keep him strong and healthy." "Breast milk is the best medicine." We hope the message is heard for the improved survival of infants and young children here. The odds are tough for these little ones.

Aftershocks
Generally, the patients wait quietly and patiently to be seen. Many have to stand or they sit on the ground, most without any water or food for the hours at a time. Children rarely cry. In the midst of a quiet clinic day, the people suddenly cried out as a group and ran into the street. They had felt and heard an aftershock. This happened three times on February 6. There is a lot of continued fear with each aftershock. Confirms that people will be staying outside, sleeping in various and sundry tents, for quite some time.

Dr. Beth Sloand, Johns Hopkins University School of Nursing

I find strength in those who depend on me

We arrive to the university hospital around 7:15. We have a short debriefing and then off to our units. There is no way to know what we are in for each day.


(Me with my two translators, James and Pierre.)

I meet with my interpreter, Pierre, and we chat about our previous night. I ask about his family, how his wife and kids are and he always says they are good. It's hard for me to comprehend they are "good" with their home destroyed and having to living in a small tent, meant for two but accommodating five. He says his kids love not going to school. I think to myself that perhaps they have not yet realized that their schools are destroyed and the devastation of the earthquake has taken the lives of their classmates and teachers.

After the brief conversation we are ready for our day, both of us knowing it's going to be long and hot. We don't give the conditions a second thought as we are immediately focused on making a difference -- bringing light to the darkness that surrounds so many here.

Arriving on the unit I take inventory to see what supplies we have for the day. I have learnt that many of our supplies are missing. Already patients are waiting for care. The long lines twist down the street. American care is here and the Haitians have welcomed it with open arms. They have a robust confidence in the work we do -- often expecting a cure for the uncurable.

As the chaos begins, there are doctors and nurses swarming the tents. Novice nurses work side-by-side with the seasoned healthcare providers. The newest additions to our ER flounder briefly, asking questions like "where is this antibiotic, where is this narcotic, will you start this IV, can you figure out what is wrong with this patient, I am new here can you help with what I should do”, etc. The intensity drives all of us to push our limits and immediately adjust to the demands from all sides.

After 10 hours of craziness in 100-degree heat, we finally come to a day's end and take time to reflect. Have we made the right calls? Have we truly done our best to make a difference? The realization that our Hopkins group will have worked over 1,000 hours within 10 days does not ease the demands I have for myself and the shortcomings I have identified within myself. It's two weeks out of my life -- a short time to do the good I set out to do.

Pierre has stood by my side all day. He's held my supplies at my side, tidied my workspace, and spoken fluently every one of my words. He comes here everyday to make a difference of his own. Knowing his family awaits him, he sets off back to his "home."

Despite leaving the ER for the evening, my mind is continuously rewinding through the day. How will I be better tomorrow? Am I good enough for these people who depend on us so much? I think of each face of each patient, each heart I have touched. The strain and stress can be overwhelming but I find a strength in those who depend on me. I will return tomorrow with a smile on my face, a soothing touch to my medicine, and shoulders to carry the burden of a broken country.

By Rocky Cagle, RN BSN
Johns Hopkins Hospital
Department of Surgery
Cardiac SICU

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A team like no other

Getting to Haiti
After a brief layover in Santo Domingo, I received a donated helicopter ride to Port-au-Prince. As our group flew over the Dominican border, lush vegetation soon gave way to rugged mountains and massive deforestation. The destruction below came into focus as I neared the city, and the images were unlike any I had ever seen.

The helicopter doors opened and immediately the smell of burning refuse filled my nostrils. “SOS” and “HELP” signs hung by the roadside where rooflines crumbled onto the street. People were digging through rubble, collecting metal scraps, large pieces of cinder block, and any other valuable items that could be reused.

University Hospital
In Port-au-Prince, I was introduced to the University hospital. Its campus was once a place where medical and nursing students flourished; now, atop paved stones of a courtyard, tents served as EDs, ICUs, and med-surg beds.

The buildings that still stood housed ORs. Buildings that didn’t survive the earthquake consisted of large chunks of cement, still holding the bodies of those who could not escape.

During my stay, the hospital was comprised of tents. On a typical day temperatures could reach over 100 degrees and we could see 600 or more patients. Cots served as beds, and creative colleagues devised effective equipment when supplies just were not available.

Clinical assessment and critical thinking were crucial in this environment — the diseases were different, space was limited, and treatment varied because of fluctuations in medication availability and a lack of diagnostics.

While evaluating patients in tent one, I quickly realized that pediatric patients waiting in a long line could be triaged separately and seen by me and another pediatric provider. This change improved rapid care of some sick children who otherwise might have died.

Non-traditional treatment of lacerations, meningitis, fractures, malaria, living larvae in wounds and dehydration took place outside the tent, under a makeshift canopy that we deemed the pediatric ED. We also tried to educate patients on the essential components of safe water supply and newborn care. This was difficult, as some new mothers had lost everything in the earthquake and had little if any resources. Children suffered dehydration and sometimes malnutrition. Resources continue to improve though as more Haitian providers offer nutrition services and maternal child primary care.

During my time in Haiti, I was amazed at people’s resilience. Most no longer had homes and even those who did chose to sleep outside because aftershocks were a daily occurrence. Still, I was awed at how thankful they were, offering a smile or a warm hug, when it is I who wanted to thank them.


This experience has left me with many memories, new and old friendships and a reflection on how we practice health care. There is still much to be done in Haiti, and I would like to thank my colleagues for their hard work and perseverance — it was a team like no other.

Rachel Lyons, DNP, CPNP-AC/PC
Assistant Clinical Professor
Columbia University School of Nursing

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Saturday, February 27, 2010

...we practiced continuous battlefield medicine...

Stanford and Columbia doctors author a detailed account of the initial situation and response for the New England Journal of Medicine:

Civil–Military Collaboration in the Initial Medical Response to the Earthquake in Haiti


"...The scene we faced was apocalyptic. Approximately 800 victims were within the hospital compound, most of them outdoors. A damaged building was filled with the patients deemed in greatest need of emergency surgery. Hundreds of patients awaited evaluation and treatment. An internal medicine ward was packed with patients with crush and other severe soft-tissue injuries, amputations, open and infected fractures, compartment syndromes, hemorrhagic shock, and other conditions threatening to life and limb. In a central wooded area outside, the ground was barely visible for the suffering people, many of whom had distorted limbs, maggot-infested wounds, deforming facial injuries, skull fractures, and spinal cord injuries. A single operating room with a few tables was staffed by overworked surgeons who amputated limbs and débrided infected tissue. The morgue was overflowing, and approximately 40 bodies were stacked near the medical ward. (more)


By Paul S. Auerbach, M.D., Robert L. Norris, M.D., Anil S. Menon, M.D., Ian P. Brown, M.D., Solomon Kuah, M.D., Jennifer Schwieger, M.D., Jeffrey Kinyon, D.O., Trina N. Helderman, M.D., and Lynn Lawry, M.D.






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A hard road, but we're moving forward


January 22…
There was incredible activity in the compound today at the University Hospital. We suffered through more aftershocks and had to permanently evacuate a large building, so once again patients were outside in the brutal heat. Under tarps and rapidly deployed tents, we treat them with fluids and attend to their now week-old wounds.

The days are nonstop from dawn to dusk. I am now assuming a role to help organize the operation, including the logistics of water, food, sanitation, operating room needs and schedules. I’ve been coordinating volunteers, arranging for shelter, caring for orphans, and interfacing with the military. The enormity of suffering is beyond comprehension, but we are learning to comprehend it and must move forward. I have learned as much as I have contributed, so that I will be prepared for the next days and the future. The people with whom I’ve worked, from Haiti and all other nations, have been incredible. We are becoming a family.


Today’s story is about a 5-year-old survivor of a week beneath the rubble. He was pulled from the ground and came to our team emaciated, dehydrated, frightened and confused. Our doctors and nurses gently hydrated him and started him on the road to recovery. With so many people affected, there will be many such stories, but for each tale with a happy ending, there are thousands with a tragic outcome.

January 23…
We saw a lot of progress today at the hospital. The surgeons are seeing a decrease in the number of patients that need emergency surgery for crush injuries and fractures, but that doesn’t mean that we are anywhere near a point where less-than-massive resources are needed. There are countless broken bones, deformities, facial injuries, and burns. We are encountering the sequelae of the initial surgeries that were performed in difficult settings. These mostly include infections that require wash-outs of wounds and revisions of the prior surgeries. This is to be expected in our situation. The U.S. military has given the hospital tremendous support in facilitating the transfers necessary to the USNS Comfort hospital ship.


The hospital campus is evolving with some decent structure. We now have a central pharmacy, three operating rooms for adults, one operating theatre (within a tent, as are most facilities) for children, and arrangements for childbirth, children, postoperative patients, and emergency triage assessments. These are crowded and extremely busy areas, staffed by dedicated physician, nurse and technician volunteers. We are moving toward 24- hour coverage.


I spoke with a young woman today, a dancer in Haiti who lost part of one of her legs. She was brave and doing her best to cope. I told her that she will dance again, and that she will be a much better dancer on one leg than I could ever be on two. She smiled and squeezed my hand. These are such special people. I have not seen one seriously injured victim complain. 
 
I am now tasked to coordinate the medical activities of all the non-governmental agencies within the compound, so I am working on medicine, essential services like water, food, and sanitation, integration among services, creation of satellite pharmacies, placement of physicians and other volunteers, and many other activities. I have never worked so hard, but have also never been more focused. My job is to make the situation improve every day for these people and for this country. The International Medical Corps team has performed tirelessly and without a whimper, and has set an example of what can be done when you are on a mission and go after it with all of your heart and soul.

January 24…
It was incredibly hot today on the grounds of the hospital. Fortunately, we have erected sufficient tents to accommodate all of the patients. We estimate that we have more than 600 patients on the grounds now, either in tents or living in a communal central area we call “the forest.” While there has been considerable progress, we have a way to go with communications (no phones yet), sanitation, information distribution, acquisition of key equipment, and development of social services like mental health.

We continue to have new patients enter the compound, including nearly 100 emergency patients today. We are receiving patients referred from the countryside and other hospitals. The operating rooms are busy with orthopedic and wound care, skull fractures, hand surgery, facial reconstruction, and the like. Neurosurgery is still not ready to go at this facility. 
 
The Swiss have a pediatric surgery service next to our pediatric area. The tent ward is full of children with multiple amputations and severe injuries. There is no candy coating this – their lives will never be the same.

A half a block away, when the wind shifts, it smells of death from as many as 100 bodies buried in the rubble of the nursing building. We have learned to adapt, to walk past this place and wrinkle our noses. We no longer need to wear facemasks. 
 
To facilitate progress, we have selected a chief of surgery and a nursing director, and have begun to make the nights as well staffed as the daytime.

I have to sneak away now and again from my organizational duties, to see patients and be a doctor. There are many doctors here to help, and we are grateful to have them. The emphasis now is to quickly transition this medical center back to its rightful owners. 
 
The city has been flattened, but the people are now picking up the pieces. We notice a decrease in the amount of garbage in the streets, and vendors are springing up selling fresh foods. The food drops have been very successful. 
 
I found someone willing to trade a hotel room shower for a medical consultation. Even though there was almost no water pressure and no hot water, it was the most wonderful shower I have ever taken.

Dr. Paul Auerbach
Photos by Margaret Aguirre






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Lessons in volunteering

The best advice I got from Dr. Rob Fuller and Matthew Howell: “When you volunteer in a disaster you feel like you have to work, work, work, and you think you need to do it all because no one can do it as good as you will…but you need to remember you are not here forever; you are here for a short period of time. When you accomplish your mission it is your responsibility to start training the next group of volunteers or better yet start training the Haitian nurses. This is their hospital, and they will ultimately be the ones working here. Be sensitive to their culture and training and do your best. You want to go back home with the feeling of accomplishment and knowing you did everything within your resources to continue what you started.”


I would like to pass this along to my nursing colleagues…you are not “Superman.” You need to remember to keep hydrated and take care of yourself before you are able to take care of anybody else. It was very hard for me to remember to drink, much less eat. I had “travel diarrhea,” so if you’re going to Haiti, ask your primary care practitioner about taking Cipro for prophylaxis. I had to receive I.V. fluids once during the stay so if you feel dehydrated, have someone start an I.V. It won’t hurt, especially if you know you haven’t hydrated adequately.

Some suggestions as to what to take if you are going to volunteer: dermabond to cover scratches, mosquito repellant, electrolyte drops to add to the water, Gatorade powder in individual packages (you can just suck on it if you can), protein bars, and Imodium. Hydrate, hydrate, hydrate!

In Haiti, I had to make the most difficult decisions in my nursing career. I would have never thought I would be placed in a situation where my decision was the “last call” on who was treated and what I had to “let go” because of limited resources, lack of medical professionals, and over-abundance of wounded people. I kept telling myself, “Gaby you can not save the world. You can only do what you are able to do. Stay focused!”

I had to keep in mind age, co-morbidity history, presence of HIV, severity of injury, and date of seeking treatment when making decisions. I wanted to treat everyone, but I had to take into account that I couldn’t waste any time or resources, from medical volunteers to supplies. I couldn’t give family members false hope when I knew the outcome would be devastating.


As a nurse—and as a human being—all I wanted to do is take away their pain and suffering. The way they would look straight into my eyes sent chills up and down my spine as their eyes told their story. Even with a language barrier, I felt a bond I never thought I could have ever experienced. Many people were left without families, a place to live, jobless, starving, and were just begging to survive! It was the most heart-wrenching experience.

Not once did I ever fear for my life or feel unsafe. The Haitians were the most grateful human beings. Coming from the U.S. you see family members bring their loved ones to the hospital and expect you to give all the care from the time they are admitted to the time they are discharged. They don’t want to spend the time to bathe or toilet their family members and push the call light instead. In Haiti, we were never asked by the patient or family members to toilet or bathe them. Even when we offered, they would say no and thank us for just being there. We often just gave patients pain meds because not one complaint would come out of their mouths. I think in a culture like Haiti you are not used to complaining. People are content with what they do have.

Nurse Gabriela McAdoo
Photos by Margaret Aguirre






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