January, 2010

Jan 30 08:23

My Perspective

 

NYU/HJD Haiti Mission
 
January 22 through January 29, 2010
 
Ken Mroczek and I joined the NYU/HJD mission to Haiti as the orthopedic contingent. We joined with Partners in Health (a non-profit nongovernmental organization that has a long and important history in Haiti). There were seven of us in all with different specialties and expertise. We all had different expectations and concerns and with three in the group being Hatian-American we had varied knowledge of the Hatian people, language and culture.
 
On the plane ride over we discussed how we would do whatever it took to help in some small way. As a surgeon, I had been very impatient in the week leading up to our departure because I knew that every day that passed my input and ability to change a patient’s outcome would diminish. We arrived in the early evening to the smell of a smoldering city and an airport and country that was in near total chaos.
 
The week mission is over now. I am home in the comfort of hot running water, warm meals and a comfortable bed.   I would like to share what I learned as a person, physician, division chief, and administrator. There are many facets to this learning experience and several had little to do with the crisis itself.
 
To describe the setting, we were placed in the largest hospital in Haiti which is the general hospital in Port-au-Prince. Even before the earthquake this was a hospital with very few resources and a barely functioning operating room. Port au Prince at this times looks like the pictures I have seen of Dresden during World War II. There are very few buildings still standing, with rubble and exposed wires everywhere. The dust, heat and smell of decaying bodies permeate the city. Tent cities are scattered throughout the parks with the bustle and traffice of a chaotic city continuing. The Hatian people are a proud people who are quite fastidious concerning their personal appearance. Even in this tragedy, nearly to a person, they were clean and well dressed with the white of their shirts whiter than white. Considering it is a city now with no running water or electricity, this is quite a fete. While I am sure there is crime, like any big city, we never felt threatened in any way and on our last day four of us walked through the city without any need for an armed guard.
 
We were sleeping in a courtyard of what appeared to be a school at the end of a runway at the airport. We had running water by day three but I never got used to the sound of C17 cargo plane one hundred feet above my head at 2 AM. Our camp was between 20 minutes to an hour away form the hospital depending on how much coffee the driver had that morning or afternoon.
 
I will start with what I saw and learned as a surgeon in order to help other orthopedic surgeons who wish to do similar work. First one must place his or her own ego aside in doing a mission like this. It is not about doing the “greatest” case or being recognized for saving a limb or a life. There are no surgical heroes in these situations and this is neither a movie nor a CNN special. We are not discovering the cure for cancer; we are simply contributing a service where we are needed.    If at home you have residents to make rounds and change dressings that does not exist here. No matter how senior, we all changed dressings (Mary Ann reminded us of this until it became second nature), looked at surgical wounds, placed IVs and transported patients.
 
Second, one must know their skill set. Ken and I witnessed surgeons and non-surgeons performing procedures that was not at all what they were trained to do. This is not okay. If there are others to help you, then use that help and assist them. Fritz and Pat did what they did best, cared for sick adults and children respectively. We joined our surgical team with another Partners in Health group from Boston Children’s, Bringham and Women’s and MGH that included trauma/vascular surgeons and Plastics/Ortho surgeons . This relationship, as I will discuss later, allowed us to accomplish more than we ever expected. There is no credentialing committee in crises and one must know their own skills and defer to others to achieve the best result. Because of my experience with limb deformity, I placed a large number of external fixators and Ken assisted on nearly every one. For a few cases I acted as the scrub nurse and/or circulating nurse when we were short nurses. We helped each other often, in decision-making and in the surgery itself.    First and foremost Ken and I always maintained the question that is what we are doing truly helping this patient in this situation? Therefore if you are reading this long winded account and you have experience with and comfotable treating orthopedic trauma, then you can certainly be of immediate help in these situations.  Residents should be accompanied by attendings and not attempt to do this alone.  If you do not feel comfortable with trauma, there is still help that you can render.
 
We had few resources and a suboptimal operating room with suboptimal sterility (especially when we first arrived). We needed to keep things simple and safe. Although certainly capable of doing so, we did not do any open reductions of fractures or intramedullary rods and made sure those cases such as a femoral shaft fracture in an adult went to an appropriate outlying facility such as the USS Comfort, a US Navy ship that had fully functioning ORs. We were also sensitive to the people of Haiti and although a number of limbs we treated may eventually come to amputation, the team salvaged all limbs and performed no amputations. The trauma victims had become very concerned that all the foreign doctors were going to do was cut off their limbs and before every surgery we re-assured the patients and their loved-ones that this was not the case. I discussed the surgery with the patient and a translator each time. While there is no informed consent forms, these are people who need to be treated with respect and caring, even in this dire situation.
 
The next lesson I learned is how to be part of a team and what skills are needed when entering this situation. When we arrived there was no fuctioning operating room and hundreds to thousands of people requiring surgery. No functioning x-ray for a few days. No xray in the OR at all.   Patients were for the most part in multi-personed tents or outside under trees or make-shift tents. Most buildings were not habitable. There were multiple groups from all over the world setting up their own little mini-camps within the hospital and performing procedures with little resources. Within one day, with the help of nurses, techs, surgeons and anesthesiologists we had a primitive but functioning OR- suite of 4 ORs. By the second day we had joined forces with the Mount Sinai group who had come with many para-professionals including a supply chain expert (Mike) and our OR had a sterility process (even without an autoclave). With only few exceptions we worked together to make this work. We scoured the patient tents and a place we called the forest, where patients were scattered under trees in the middle of the facility. There was one physician trying to help 50 patients. We found patients with untreated open fractures, untreated pelvic and femur fractures and open and/or infected stumps. We prioritized the need and actually created with a nurse (Stella) and an anesthesilogist an OR schedule. We often made rounds with an anesthesiologist in order to make dressing changes more humane. There was a time when we had 20 patients in a tent all on Ketmaine. It was like a 1960s LSD party. We had one tent which was run by critical care and ICU nurses and we made that our post op critical care unit. These Dartmouth nurses were talented and incredibly dedicated to these patients. We could not have done it without them. As the days went by we actually created a map of the facility and with the help of BB, an emergency room doc from California, we created a pre-op unit which patients either were treated by us the French, the Swiss, the Norwegians or were transferred to other facilities. With the help of International Medical Corps (IMC) led by Paul, Bob and Anil, we were able to identify, which patients would go where and with Colonel Malsby of the US army, we became as efficient as possible in getting the patients the appropriate care they needed as quickly as possible.
 
How do you deal with so many small groups who were running their own show? This is a difficult question and is unique to crises. Unfortunately, several groups were more interested in the media and the cameras then in the optimal care of the patient. The media is looking for the miracle story and/or the crisis problems that care takers are not solving. For the most part these do not exist and it is never as good or as bad as some of the media portrayed. We solved this problem by constantly engaging the international groups. We used our pre-operative area to feed the French contingency surgical patients. We shared resources of equipment etc with whoever needed. I would start my day at the Swiss Pediatric tents talking to Axel, their surgeon, and seeing how I could help. Gradually barriers were broken and all was collegial if not actually friendly.  Amazing that there can be turf wars when there is so little at stake. Left to nature, we would have had the Lord of the Flies. The goal was the quality of patient-care, not us.  There most definitley needs to be a more coordinated multinational response team.
 
 
Let me say a few words about the us, i.e the surgeons. Ken Mroczek, chief of foot and ankle surgery at NYU/HJD, Johnathan Gates, Medical Director of trauma surgery at Bringham and Women’s Hospital, Mary Ann Hopkins, General Surgeon, NYU medical Center,   John Meara, Chief of Plastic Surgery at Boston Children’s hospital, Gary Rogers, Plastic Surgeon, Orthopedic Surgeon, Hand Surgeon, JD, MBA, MPH at Boston Children’s Hospital, Joaquim Havens. Ex-Navy seal and Chief Resident of Surgery at Bringham and Women’s Hospital, Bill Perenteau, Chief Resident of Surgery at Bringham and Women’s Hospital and myself, David Feldman, Chief of Pediatric Orthopedic Surgery at New York University and Hospital for Joint Diseases. Those are all pretty impressive credentials. There was not a moment of discord between any of us in the group. Everyone did jobs from the most menial tasks to the most complex surgery without a single word of complaint.   We were colleagues and we became friends. We utilized each other’s surgical skills to make the patient outcome the best it could be. One case in particular that stands out for me is a five year old girl with an infected complete degloving injury of the upper extremity with a multiply fractured and dislocated elbow. The child had been treated in another part of Haiti and was sent in with a seemingly unsolvable problem. Gary Rogers and I worked together as if we had been working together for years and jointly we were able to fix the elbow and then transport the child to the Comfort for completion of her care.
 
 We worked hand in hand with the nurses and anesthesiologists (who were the best and most dedicated I have ever worked with) to make an operating room that was real and functioning. On our second to last day we performed 26 operations closing wounds, skin grafting and completing what we had started and on our last day we were able to transition this OR to the Hatian doctors. This is the part I am most proud of.
 
I have learned that the first response team MUST include trauma, plastic and orthopedic surgeons with the emergency doctors. These surgeons must be willing to be the first line in order for example to splint extremities correctly and prevent unnecessary amputations and amputations performed incorrectly. As you exit the first days of a crisis you need an internist and pediatrician to take care of sick patients, you need ER doctors to triage and treat, you need talented anesthesiologists, trauma surgeons, plastic surgeons and orthopedic surgeons. Within a week, the role of the trauma and general surgeon diminishes and you need more orthopedic and plastic surgeons. As a team who wishes to be self-sufficient, you need OR techs and experts in setting up an operating room. You need talented indefatigable OR and ICU nurses. You also need to incorporate the local people to help you in all ways from physicians to transports.
 
I will end this review with a word about the American Armed Forces. Unfortunately, previously I  had little to no experience interacting with our armed forces. In Haiti the army maintained order and we worked closely with them. Each soldier I came in contact with was expertly trained, intelligent, disciplined, kind, helpful and dedicated. The Medics operated with us and at times they too performed the most menial tasks always with smiles on their faces. One unfortunate story was of a local doctor who delivered a full term still born child in the Swiss OR. The doctor, for unknown reasons, discarded the dead newborn child on the floor. The US medic (Patrick) asked the doctor to pick up the child. The doctor stated, “it was not his job”.  The soldier instead of creating an incident, picked up the child and wrapped the body and treated it with the respect it deserved. One story and there are many others. Without the tireless work of the US army, Haiti could not have pulled through the first weeks of this crisis. We often forget, due to media reports, how incredible these true patriots are and my attitude and love of these men has been changed forever and I will support and help them in every way possible.
 
The cameras will soon leave Haiti except for an occasional follow up human interest or “how are they doing now?’ story. I will return to Haiti in the next six weeks and partner with an effective NGO to help follow the numerous patients treated with external fixators etc. If you wish to help don’t do it alone- lone rangers don’t function well in these settings. Join a mission or an NGO and find where you can be most useful with the skills that you have. If you wish to give money, then give it to an organization that you know exactly what they are doing. I hope I have become a better person from this past week but I will leave that for others to judge. I will sign off by thanking PIH for creating this group, Natasha for dealing with all the nonsense of accommodations and transport, Fritz Francois for his impassioned care of patients and running this mission, Pat Poitevien for sharing her language, cultural and medical expertise and NYU for allowing and enabling us to do this mission. I also thank with all my heart: Stella, Jay, Prisca, Trish, Liz, Lucy, Pam, Joanna - the nurses. As well the nurses of Mount Sinai in NYC who were wonderful and I am grateful to them. I also thank Craig, Emily, Monica, Daina, and Dave the anesthesiologists and all others I have forgotten who made this an unforgettable and effective journey. To Ken, Gary, John, Mary Ann, John, Bill and Joaquim -the surgeons, you truly were the best and most humane group of now true colleagues and friends I ever could have hoped to work with.
 
 
Jan 29 11:52

A day on the wards: 12:30pm

By noon steady sunlight streaming through the small windows of the critical care unit had become tributaries to the stiffling humidity and heat on the ward. A few volunteers had arrived to assist the patients. They were cherubic faced US college students who wore bright yellow t-shirts announcing their affiliation with a Scientology group. They assisted with turning the patients, changing dressings, and running errands. In search of water I walked out of the unit, first past the white, then the green iron gates to arrive outdoors. I stopped and allowed my eyes to acclamate to the bright light and to survey the scene. One of the main arteries of the hospital grounds coursed directly in front of the unit. The road was congested with soldiers, transporters, doctors, patients, and families only barely avoiding crashing into one another.

A few lumbering trucks delivering supplies blared their horns in hopes that a path would somehow open up without someone getting trapped beneath their wheels.

"The Forest" stood directly across the road and I could hear voices, mostly women, joyfully singing church hymns. All around the outskirts of "The Forest" and along the road that encircled the medical campus, tents had been erected. Each tent or set of tents was labeled with the following information:
1. Service provided: Pediatrics, Post-op, Pre-op, etc.
2. Physician in charge: Dr. "Bruce", Dr. "Jim", Dr. "BB", etc.
3. Affiliation: Association of Haitian Physicians Abroad, Red Cross, Red Crescent, International Medical Corps, Swiss, Norwegian, etc.
The International Medical Corps (IMC) was responsible for coordinating the medical efforts at the hospital. They consisted of physicians with disaster relief experience. In essence they served as the de-facto leadership since so many in the hospital administration had been directly affected by "The Event". The biggest challenge that the IMC faced was how to coordinate all the responders in the most efficient manner, how to transfer critical patients when needed, and how to get necessary supplies and equipment.
In the rush to provide services reflecting the expertise of various groups, the medical campus had been splintered into silos that were now struggling to integrate not only with themselves but also with the Haitian faculty of the General Hospital. This was a problem even within particular fields such as surgery where battle lines were seared along institutional affiliations: Mt Sinai, NYU, Boston, etc. Some groups were more successful than others at bridging those divides and found a way to work together. Others, feeling wronged when it came to access to patients and procedures, packed up and left Haiti before completing the time they had promised to serve.
As I stood in front of the unit, a thin young man about seventeen years old wearing a black knapsack approached me. He was one of many such young men I had seen lurking around the hospital grounds. Some worked as transporters, others as interpreters, but the vast majority didn't seem to have a role. Reaching my location the young man briefly raised his open right hand as a form of greeting, and nodded his head while reading my name. Physicians had begun to write their names directly on their shirts or on a piece of white medical tape that they then applied to the left upper chest region. My "name tag" read: "Dr. Fritz".
Given the popularity of the name "Fritz" (or of its derivation) in Haiti, the young man quickly surmised my background and began speaking to me In Creole. After introducing himself as Jean-Marc and telling me of his losses in the quake, he proceeded to ask for my assistance in securing a job at the hospital. I listened quietly and intently but then in turn had to explain my limited role as a visiting volunteer to the hospital. Jean-Marc remained unconvinced that my status as a physician could not somehow secure employment for him and although he continued to smile politely his disappointment was unmistakable. Many other such encounters would take place in the days to come, and my ability to assist would not improve. As Jean-Marc walked away, I wondered whether a similar life with limited opportunities would have befallen me had I not gone to the US at the age of 10. This was my first time back to Haiti since I left...my first chance to reflect, on the ground, how different things could have been, and to wonder how different things will be.
As a group we were here to help repair broken limbs, overworked hearts, clogged kidneys, inflammed livers, drowning lungs, swollen bellies, and infected wounds. We labored tirelessly in the operating rooms, in "The Forest", in the critical care unit, and in the tents.
But perhaps those whose suffering could most easily be alleviated...those representing Haiti's future...those like Jean-Marc...we simply did not see at all.

Jan 28 10:04

Sirius XM - Doctor Radio Broadcast - Live from Haiti

Orthopedic Show with Hosts Drs. Ramesh Gidumal and Nader Paksima speaking
Via Satellite with
HEART'S Drs. Kenneth Mroczek and David Feldman
Monday night, January 25th at 7:15 p.m.
Channel 114

Audio: 

It look's like you don't have Adobe Flash Player installed. Get it now.

Jan 28 08:10

A day on the wards: 10:30am

Following morning rounds, I moved around the dimly lit ward trying to prioritize patient treatment plans based on available resources. THIS was suppose to be the critical care unit...sixty patients.
There were no monitors with colorful lines and numbers reporting heart rate, blood pressure, oxygenation, and respiration. No ventilators with sing song beeps and whistles to warn of preset highs and lows. No suction canisters to clear secretions from congested airways. Yet, it was clear that so many of the patients would have benefited from such instruments. In a corner there was an old electrocardiograph machine locked into an old movable metal frame. Multicolored wires were intertwined like an intimidating snake pit and it wasn't clear that the machine had been used in the recent past.

I returned to the beside of two of the sickest individuals.
In bed 4 of ward 1, a 39 year old woman with peripartum cardiomyopathy presented when her failing heart could not effectively move those little oxygen toters along their routes. Like Port-Au-Prince rush hour traffic, the congestion had a suffocating effect. Beads of sweat formed on her forehead as she sat up on the bed with both hands at her side to stabilize her frame. She repeatedly threw her shoulders back and heaved her chest upwards in an effortful attempt to get more air into her drowning lungs. After much bargaining we had managed to secure one of only four oxygen tanks in the hospital and was now providing her with some support in carefully measured doses for fear of depleting the tank. Her husband stood at the bedside with their two month old baby girl in his arms. He rocked the child back and forth hoping that the mother would soon be ready to resume nursing...they had no means of securing other nourishment. From her position the mother would steal glances of the baby and then return to her chore of trying to breathe. A nurse moistened her lips with water.

Treatment with intravenous medications equivalent to water pills? NOT AVAILABLE.
"Okay" I thought "I'll use whatever can get the fluid off her lungs...just keep it simple...just keep it simple."

In bed 1 of Ward 2, there was a barely responsive woman whose poorly functioning liver no longer adequately cleared toxins from the blood, thus allowing them to pickle her brain into a stupor. Treatment with lactulose or non-absorbable antibiotics?
NOT AVAILABLE.
"I need to reduce the toxins..."
In the middle of that thought the physician who previously ran the ward reappeared. He was now coordinating transfers between wards.
"Hey, how's it going?"
-Listen, we need some basic meds here, like water pills...
"Yeah, I know. Okay, I'll make a run to central supply. Can I tell you about a new patient?"
-Where am I going to put the patient?
"We can move some into the hallway"
-The hallway?
"It's not a great option but we need beds"
-We also need more internists. What about starting to think about who's going to cover all these patients tonight? Is there a plan?
"No"
-So what am I suppose to do?
"You can't expect to save everybody"
-It's not a matter of expecting ro save everybody, it's about trying to do our best. Supposedly there are all these resources that were flown in and all these doctors floating around this place. Is this really our best?
"It is getting better. Besides, better that one dies to save two"
-So how many of these sixty should I choose to let die?
"I hear what you're saying. I'll work on the meds and coverage"
He shuffled away to the next ward and from the sound of metal grinding against cement, I could tell he had started to shift a bed into the hallway.

I went back to moving around the ward. Repeatedly I was stopped by a patient's relative who wanted to advocate for "serome", the name given to the bags of intravenous (IV) fluid. It did not matter whether the IV bag contained medications or simply water with a little bit of salt and sugar that provided no nutritional support. Perhaps seeing the fluid drip down from the IV bag and snake through the plastic tubing into the vein of a loved one was therapeutic for the family as well as for the patient. After all it was at times the only proof that the patient had not been completely forgotten in the cold dark bowels of a ward whose iron gates were locked at night.
I peered down at Mr Doe...John Doe to be exact. The name had become quite popular among the elderly who mysteriously appeared at the hospital. They were either not able to provide any coherent information about themselves or were completely non-communicative. He had a large pressure ulcer on his buttocks which was in the early stages of infection. He needed antibiotics, dressing changes, and nutritional support. He was in no condition to feed himself since he seemed to choke with even small sips of water. I had asked the nurse about a plastic tube that I could snake through his nose and down his throat and into his stomach to feed him.
"I don't think we have those tubes...I have not seen them in the week that I've been here. But even if we have one, we don't have any food to put through it"
As I looked down on the cachectic John Doe, I became aware of a commotion outside. A large crowd had gathered and there were loud exchanges even though I could not immediately make out what was being said.
I walked closer to a small window.
"WYCLEF!!!! WYCLEF!!!!" The crowd chanted.
Wearing a blue shirt with glittered lettering promoting his charity, the popular Haitian singer Wyclef Jean had arrived at General Hospital. Word had spread quickly and the crowd was now following his every move.
I turned back towards the lonely old man laying on the bed and stared at his bony frame.
There were no crowds around him. No family, no friends, no one at all.
Who was he? Had anyone cheered for HIM during his life?
"JOHN DOE!!!! JOHN DOE!!!!"
I would never know.

Jan 27 00:38

A day on the wards: 8:30am

Standing at the entrance of the large park in the middle of the General Hospital in Port-Au-Prince it was easy to understand why the builders had approved it. The branches of lush tress provided an inviting canopy beneath which one could allow day dreams to float towards the distant mountain peaks that seem to tickle the sky. A pathway that began straight soon gave the option of semicircular walkways leading in opposite directions. Radiating from these paths were other walkways that led to the various hospital buildings.
After "The Event", the moniker now used by some Haitians to refer to 1/12/10, the park took on the special role as host to patients who no longer trusted the indoors. Tents were set up and beds were arranged in seemingly random fashion across the park. Gone were the days of hearing chirping birds and seeing butterflies. Occasionally a sliver of sun could be seen meandering it's way between branches and tents to scorch the already barren earth.

Walking though what the physician responders were now calling "The Forrest" it was easy to see how difficult it might be to locate a particular patient.
I strolled through and gazed at families washing clothes and cooking meals next to the beds of patients. Sometimes two or three family members huddled at various angles on the patient's bed as if on a raft boat that would soon set sail across the sea of people now inhabiting the park.
This however was not my destination.
I emerged from the park and walked towards a low rise building with a set of cold impersonal and imposing set of iron gates.

The once carefully brushed green paint on the gates had long surrendered it's luster to dust, rust, and cryptically etched initials and short messages.
Who was "AG", "NB", "CF"?
Why had someone scratched:
"Manman Marie aide nous" (Mother Marie help us)
"Bon Dieu" (Good God)
"Delivre nous" (Deliver us)
I walked through the entrance of what until recently was solely the women's medical ward. The damage suffered by the men's inpatient unit during the quake led to coed wards.
Twenty steps from the entrance, another gate, this time with white peeling paint. It was not immediately clear whether the gates were intended to keep individuals in or out. The dim lighting in the anteroom did not invite optimism.

Even in the best of times one could imagine that little attention had been paid to wall decorations, plants, or other embellishments. A health education remained the lonely resident of a small bulletin board.
It occurred to me that while many outdoor tents had been set up for patient care due to fears of another quake, this was the only INDOOR inpatient ward.
Turning to the left there was a long narrow corridor with four entry ways marked by the sunlight that tried desperately to bend in competitive announcements of the extent to which they had tried to flood their respective rooms.
A sheepish look back towards the green gate confirmed that it was not being closed behind me and I steeled myself as I began to walk down the corridor.
Before I could reach the ward I smelled it.
It was the distinct odor of flesh that had given occasion of a meal to organisms feasting and releasing gases now reaching my nose. You could be fooled to think about fruits...but it would be rotting fruits.
The plan was for me to take over this new coed critical care unit that housed both medical and surgical patients.
I stepped into the first ward area and noticed that halfway on the right side of the room there was a doorless entrance leading to a second unit, which was connected to a third, which was finally connected to a fourth unit.
I introduced myself to two nurses and we began to discuss patients by going to each bed in succession. The nurses, both volunteers from the US, diligently took notes on orders as well as other tasks to perform. I knew that results from the few serologic tests available would take 2-3 days and that except for the most acute cases, radiology was almost non-existent. These minor obstacles, I thought, could be overcome by a careful history and physical examination. At times I had to maneuver around a relative resting across the bed to reach the patient's limbs.
The physician who had previously run the unit had agreed to join the morning evaluations. Almost an hour into rounds, as I reached the 12th patient, he pointed to his watch.
"Hey...uuh...you have other patients"
-Yes, I know...two more.
"No. The other wards"
-What? Where are the other doctors?
"One guy showed up yesterday but I think he got spooked and did not come back after morning rounds"
-So who's going to cover those wards?
"You are it"
-How many patients are there?
"Well we lost three overnight...so you only have sixty"
One doctor, two nurses, sixty patients...things were about to get interesting.

Jan 25 00:11

The nice wife

The door of the pre-op holding area was guarded by two armed members of the US military. The soldiers had been stationed there to prevent a steady stream of individuals from disrupting the flow of the operations. Some were curious visitors wondering about the procedures going on inside, others were hungry scavengers searching for water and food, while still others were hopeful relatives searching incessantly for the Jocelines, the Tinelles, the Brisbes, or the Danielles that they had not seen since the quake. Many had been walking from hospital to hospital in the hopes that there would be a surprise reunion. They carried prayer beads along with pictures of smiling faces and bright eyes that could not have foreseen this future. They told themselves that the joy of finding the missing person here...in this final bastion of hope...after so many days...would overshadow any shock of missing limbs or disfigurements.
It was with this sentiment that a lanky man with an equally thin mustache arrived at the pre-op door along with the midday humidity. He wore a white shirt with a black and white sketch of a menacing dragon, warm-up track pants, sneakers, and a baseball cap. One could imagine that he had just gone for a leisurely stroll in the park, however the sweat soaking his shirt spoke more of a man who had spent some time walking in the hot Port-Au-Prince sun.
The guards stopped him from entering and he began a frantic plea while waving a well worn black and white photograph of a woman. The barrel chested guards with their crisp uniforms and rifles pointing downwards were imposing figures to be sure in front of the thin man. But the most intimidating aspect was the fact that the man's creole bounced off the guards ear drums without so much as a hint of stimulating understanding.
One of the porters who had previously heard me speaking creole, ushered me over to the scene.
The thin man spoke rapidly for fear that at any moment I would lose interest and simply turn around and go back to my work.
"Please...my wife...I'm looking for my wife."
-Okay
"Please...she's here?"
He points to the picture of a face that looks vaguely familiar, although younger, better dressed, and more well rested than the person I am now thinking about.
-What is her name?
He tells me breathlessly and the connection is made in my mind. Two hours prior I had written a similar name down on a piece of yellow notebook paper along with the procedure to be done and taped it to the woman's lower right limb.
-Come with me.
I bring him to a room with three patients resting on stretchers, all women, all with lower extremity wounds. I point to one woman in particular wearing a yellow blouse and resting with her eyes closed. Perhaps she was shutting out the world along with the blood soaked bandage that wrapped a stump that was once her right foot.
Before I could say anything, he called to her and she opened her eyes.
A smile brushed across her face as well as his, perhaps for the first time in many days.
He bent down and embraced her and for what seemed like a long time, no words were exchanged between them.
None were needed.
He held her hand.
He brushed her hair.
He touched her face.
Straightening up he took off his cap in a swift motion and began to fan her. With her head turned towards him she closed her eyes again, but this time as if she had found some real measure of comfort, some real hope.

After observing the reunion for a few minutes, I approached him.
-We are going to take your wife inside to clean her wound.
"Thank you...yes...that's my wife..." Then a pause.
"Okay...well...this one...this is not the wife I have at home"
-This is not your wife?
"I keep her in a house...she is my wife. The house fell down...I feel bad. But my other wife at home is my wife...she is okay. This is my other wife."
-Your other wife?
"My wife at home is not like her...this is my nice wife."

Jan 24 19:38

A labor of love...

After assisting on muliple deliveries in the maternity tent, Prisca Bernard-Joseph attends to a young pregnant woman with a head laceration, pelvic fracture, and left foot abrasion. Along with her nursing skills, she uses her reassuring smile to lessen the patient's apprehension about receiving pain medication that might somehow cause harm to her unborn child.

Jan 24 07:49

Scenes from the General Hospital

An examination room


Sign marking the Pediatric Tent Ward.


Dr. Patricia Poitevien discusses cases in the pediatric ward.


The outdoor medicine ward.


An emergency room patient waits to be seen.


The nursing school affiliated with the General Hospital. It is a three year program. No one in the 2nd and 3rd year classes made it out.

Jan 24 06:57

Sunday 1/24/10

Tent City is awake.


Everyone slept a bit better last night.
The first car left for General Hospital at 6:40am.

Location:Port-au-Prince,Haiti

Jan 23 22:32

Pouki sa? (why?)

Danielle Bien-Aime is a 25 year old previously healthy woman whose left leg was trapped by fallen debris for 18 hours. Some friends died around her but she was pulled out alive from her home. Due to lack of services at Port-Au-Prince immediately after the quake, a friend drove her 90 minutes away to Cange where 30 hours after the trauma she underwent an above knee amputation. Her post-operative course was complicated by rhabdomyolysis induced renal failure. She was transferred to the General Hospital and was started on dialysis. She became febrile and was noted to have necrotic tissue at a poorly healing amputation site.
Dr. Mary Ann Hopkins completes an initial assessment.


Next, in preparation for wound debridement, Dr David Feldman examines Danielle.


Later, Dr. Hopkins taught some volunteers how to properly change the bandages.
When I went to do a pre-operative assessment on Danielle I reviewed the care plan with her and asked if she had any questions.
She only had one:
"POUKI SA BAGAY SA DO RIVE MOUIN?"
(Why did this thing have to happen to me?)