The early hours of the afternoon marked a steady stream of apprehensive patients arriving in the waiting area of the operating room (#22 on map) where David Feldman, Ken Mroczek, Mary Ann Hopkins, and Diana Voiculescu continued to immobilize bones, deep clean wounds, and explore abdomens.

A man on a stretcher examined his x-ray with great fascination while waiting his turn. To anyone who approached he would offer a well rehearsed argument against any surgery on his leg for fear that it would be amputated:
"Moin pa we anyen la. Moin bon" (I don't see anything here. I'm good)
In fact, the x-ray showed a clear tibial fracture.

In the pediatric tent (lower right corner on map), Patricia Poitevien had just identified a child who was slowly drifting towards respiratory distress. Without the benefit of mechanical ventillators an intubated child would need someone to stay by the bed and manually squeeze precious air into the lungs with the aid of an ambu bag.
Where were the ambu bags anyway?
The best option for the critically ill was to arrange for a transfer to the US medical ship, The Comfort. Some nearby children cried from hunger while still others laid quietly on their backs staring up at the bland ceiling of the tent.
No dancing bears, smiling clowns, or goofy duck characters would entertain them.

Nestled in between the pediatric areas, were two other tents that had been designated as Maternity Wards (lower right corner on map). It was there that Prisca Bernard-Joseph held hands, administered pain medication, and gave encouragement to pregnant women who at times seemed preoccupied with the uncertainty into which they would deliver their children.
Why hurry up and push? This was not a place for children to set their sights.

Back on the dimly lit and poorly ventilated critical care unit (#6 on the map) tensions were mounting between the patients and the legions of flies that seemed to have summoned reinforcements.

Groups of them swarmed around day-old soaked bandages and tried to land on exposed skin.

At times the number of insects that successfully remained in close proximity of a patient became an early warning system to the deteriorating condition of that individual.
With only two nurses for all the patients on the unit it was impossible to attend to everyone's needs in a timely fashion. The situation was made worse by the fact that the two english speaking nurses had only one interpreter to share. Yet these patients and families who had already endured so much hardship, were steadfast in the dignified and patient manner in which they dealt with the situation.
Many patients suffered quietly until the very last moment when the unbearable pain would drive them to the edge of consciousness. At that point a very faint plea might emanate as I passed by:
"Dokte, fe ou bagay pou moin" (Doctor, do something for me).
One of the quietest patients was a 17 year old boy who days before had presented with massively swollen legs from crush injuries. He now wore precisely made foot-long surgical incisions down both sides of each leg. While these unsightly fasciotomies saved his lower limbs in the short term by releasing built up pressure, they now threatened to take his legs by being portals to possible infections...as his daily fevers (despite antibiotics) would suggest. He never watched when his bandages were being changed, choosing instead to bury his face in his right arm. He remained in that position well after cleaning solution had been applied to the raw wounds, poorly healing tissue had been scrubed or cut out, and new bandages had been applied. Only the rapid rise and fall of his chest hinted that the pain medication he had received prior to the wound care might not have been sufficient.
He did not ask but graciously accepted the morphine that I brought him.
"Merci" (Thank you)
I tried to get him to talk.
-So what do you think of Wyclef?
"He's good."
-Yeah? Sounds like you have another favorite.
"I don't have a problem with him. He's okay."
-What about you? Are you a musician?
"Not really. I just play sports."
All of a sudden I regretted the direction of the conversation.
He shifted to pull himself up in the bed and grimaced as he did so.
"Before this...I wanted to be a professional soccer player...that's what I WANTED"
He emphasized on the past tense.
My stomach sank.
Two transporters arrived to take him to the dialysis unit run by Medecins Sans Frontieres.
He was on his second session for rhabdomyolysis.
I touched his arm and offered
-Kenbe fem (hold firm)
He nodded and simply buried his face in his right arm again as he was carried away.

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.

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.

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.

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."

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.

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.

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

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?)

Riding through the various neighborhoods in Port-Au-Prince, it is not possible to deflect the continuous sensory assaults.
First the eyes become transfixed on individuals whose actions seem so diametrically opposed to the scenery:
A homeowner carefully sweeping the front of her house although the street is filled with trash to the point of being impassable.

A man getting his shoes shined at a stand near horribly mangled property.

The ears are tickled with the sound of car horns, staccato swears, and wall-street trading floor type announcements of merchandise to sell.

The nose is never allowed to develop a comfortable familiarity with the air. Here, there are the choking fumes of cars jockeying for position...now there is the inviting fragrance eminating from the sidewalk stand of a FRITAILLE (fried food) merchant...

a few feet further, the repulsive scent of rotting flesh hidden from view beneath rubble.

The skin fevereshly attempts to compensate for the heat and humidity. The dews of sweat that form only seem to invite flying insects.