Two days ago I walked into the courtyard of CDTI (the hospital where we had been working for the past week) and for the first time since my arrival it appeared empty. It wasn’t, of course. There were still ten large tents with eight patients in each plus many more tents where other people were waiting to go to other locations or family members of patients were staying. But the courtyard was, for the first time, not congested with patients with crushed limbs, infected wounds, and burns waiting to go to surgery. The hallway leading to X-ray, usually jammed with injured people, was empty. I got our driver and Brother Jim (our wonderful Jesuit brother) to go with me to make another sweep of any refugee camps that we came across to see if there were yet more injured waiting to be connected to definitive care. As expected, we encountered hundreds of people requesting minor care – all the same problems that clog ERs back home – but there were few if any remaining untreated victims of the earthquake. Moreover, larger organizations such as the Red Cross, Doctors Without Borders, and the UN were making their presence known. And in some cases, they made it clear that they did not need or want assistance from small NGO groups like ours. So, despite my original willingness to stay much longer, it appeared that I was no longer needed. I thought of all the work waiting for me at home and then I paused, taking a deep breath and hoping for some divine guidance. And then, reluctantly, I decided to leave Haiti.
Even as I made the decision, I saw the faces of some of my new friends who planned to stay longer, and felt that I was betraying them. But once the decision was made, I committed to it. Loading my pack to go home, I tried to leave anything and everything that I could. Everyone promised to stay in touch, but I knew it was possible that I would never see some of them again. I trudged to the area of people waiting for humanitarian flights out on military planes. The ICE inspector saw my military ID, my Marines T-shirt and Navy cap, but was confused by my five-day beard and the filthy clothing. The X-ray machine picked up the K-bar knife that I carry everywhere buried deep in my rucksack. The inspector told me he would have to take it from me. There was no way I was giving up a knife I had carried through two combat deployments. I called my friend to return to the airport to pick up my knife. The ICE inspector interrupted with a whisper, “Forget it, just bury it in your pack.” Finally making it to the flight line I realized that the body scanner had missed the equally large bandage/tissue knife in my pocket. Oh well.
For the next 14 hours we waited on the flight line as plane after plane came and went without picking up passengers. Each time the refugees would get more anxious and agitated. Finally, near midnight, a C-17 agreed to take on passengers for the return trip to Orlando. Over 300 refugees and returning aid workers scrambled to get in line. When we got inside the plane it was empty. We were told to sit on the floor with one large group strap across our legs to serve as a seat belt. Then another plane arrived willing to take passengers. The crew asked for volunteers to take the next flight, but only five of us were willing to get off the bird we had.
So two hours later five people were flying out of Port au Prince headed for Orlando. I chose to go on with the crew to Charleston, SC, the aircrafts home base. Ten hours after that, I finally arrived home in Maryland, exhausted after waiting/traveling for 36 hours.
Now I’m clean, fed and rested and wondering what to make of my experience. Though I’m sure I’ll have more observations as I process my experience, here is my first take.
1. Whatever the source of devastation, people will survive. Virtually every building in Port-au-Prince is broken or destroyed. Thousands died and were injured. But most survived.
2. The role of emergency physicians is in the first few days following a disaster. Big organizations take time to deploy. If EPs want to play a role, they must be prepared to deploy quickly.
3. You can’t assume political cooperation. While most countries want help, you can’t assume that they will want exactly what you have to offer. Take charge people are absolutely necessary, but have to be tempered by political realities. For example, many amputations were performed early in the disaster. It was probably necessary and appropriate, but now those that did those amputations are being heavily criticized. Others who tried to step outside the law and help children are in prison.
4. You can’t assume even all the NGOs will cooperate. Doctors Without Borders, a fine organization that has done wonderful work worldwide, at times reflected their French origins by demonstrating open antagonism to American doctors and nurses. Turf wars exist, even in hell.
5. Speaking of hell, the road there is paved with good intentions. It’s not enough to be willing. Aid workers must have applicable skills and the support base. Many people arrived in Haiti hoping to help, but simply consumed resources that were intended for others. Those wishing to help must have survival skills, their own food, water, etc…
6. No matter what you do, it is only a drop in the ocean. There are no saviors of the world in a large scale disaster. You have to be content to help one at a time. That being said, every person needs to be treated as a human being with their own problem and not as a group.
7. Be prepared to be changed forever. You cannot look at suffering on such scale without asking some fundamental questions about the meaning and purpose of your life. Let it happen. It might be painful and a little frightening, but it’s worth it.
Today I am at a UNICEF clinic in a refugee camp. What we’ve discovered is that we’re getting into lumps and bumps, sniffles and colds, and we’re having a hard time finding the serious injuries. We’re looking for those people, and finding one in a hundred, or even one in five hundred. It’s hard work to find the ones that really need the acute care. They’re out there, by the hundreds and maybe thousands, we don’t know. But finding them is very difficult. They’re laying in refugee camps that are nothing more than scraps of sheet plastic. They are just everywhere.
There are wide open parks here that have now become tent towns. The people who are really injured don’t get up, they’re just stuck in their tent. So we go through and eventually find these pussing injuries, these untreated broken bones. Until you walk the camps, you’ll never find them. If you set up a clinic, you’ll get all of the moms with kids with sniffles while the people with broken limbs lie alone in the camps. They don’t make it to the clinics.
Today, for instance, we found a young woman with an unreduced fracture of her humerus. It was a mid-shaft humeral fracture that wasn’t treated properly at all and really needed an operation. She, like so many others, had had one pass with a health care provider. She even had an X-ray, but her splint was poorly done and it wasn’t doing anything for her arm. But she thought that she had been treated so she was sitting in her tent with an arm in excruciating pain. She’d been that way for two weeks. We’re literally having to find them one by one. They’re not in large groups.
Everyone has been relatively cooperative. There are a lot of doctors and a lot of supplies. It’s not so much turf battles – maybe you get that in the operating rooms because space is so limited. When you get out in the camps, everyone is very, very helpful. The hard part is just finding the people. Sometimes you’re seeing clean, fresh dressings and sometimes their wounds haven’t been dressed at all. It’s a hodge podge.
After I finish with UNICEF I’m going to take a patient over to a hospital in Sacre Couer and I’m going to ask if they will need my assistance after Team Rubican leaves the country. If they do not, I won’t have any more support and I’ll probably have to head home.
We’ve got medical supplies coming out our ears, but they told us when we left the camp this morning that we had no more water. They said they were going to go try to find water for us. I’ve got a bottle on my back and one in my pack, but that’s the end of my personal stores. I’m assuming we’ll find more – we’ve got a logistics expert tracking it down – but we’re getting a little hungry. I had nothing for breakfast and I have yet to eat my Powerbar for lunch. I’m hoping that I’ll get something for dinner.
I’ve been taking patients who need surgery to Sacre Coeur (Sacred Heart), where they can receive treatment, since I know the doctors there. I put them in the back of a truck and take them there personally. When you walk into the hospital, you immediately hit an interior courtyard which is set up as a triage emergency area. It’s a big giant mess. A doctor sits out in the middle of the courtyard with hundreds of people around him, sorting through to find the ones that need to go in for surgery. I was able to bypass this, discuss the patient with the doctor, and take them straight inside. Yesterday I ordered my own X-rays, read them and handed them to the surgeon. It made for a very efficient system.”
I haven’t made contact with the navy yet. We wanted to get a feel for what we needed and how difficult it was going to be. So far it looks relatively simple. Right now we’re just trying to find the people who are most sick. There are a lot of people coming in complaining of back aches that they’ve had forever, but since there is a doctor here they all show up.
We had a surgery team show up Sunday and they heard [that there was a need for surgeons]. They went to four different hospitals and all four said that they had all the surgeons they needed and refused to give them any space. Operating space is very limited. These guys are working very hard, 8am to 10 at night.
I’m concerned about follow-up. I asked one doc what he was working on and he told me that he was putting on external fixatures. When I asked him who would be taking these fixatures off, he said, “I don’t have any clue.” When I asked him what had happened to the patient he had just put a fixature on, he replied that she “went back out and lay on the ground.” Somebody, someplace is going to have to take that fixature off and they won’t have clear information on when it was put in. We’re talking 4-6 weeks down stream somebody has to take over these cases and they’re not even in the hospital. A lot of them have been lost to follow up. Like the little girl I saw today: the bandage I put on her will probably be the last bandage she gets.
“When we got off the plane, Port-au-Prince was almost completely black. There is almost no light here. We unloaded the aircraft ourselves and it was just a giant scramble getting all the bags off. We had bags in seats and the inside of the aircraft was total chaos. It was shocking that we got all our gear off. We were met by a team Rubicon leader named Jake Wood, a 6′ 5″ ex-marine sniper who was now a medic. On his own, Jake had decided to come down to Haiti and help out. He’d grabbed a couple friends – some people he didn’t even know – grabbed some sleeping bags and flew to Santo Domingo, DR. They rented a car and just drove in to Port-au-Prince. They made a connection with a Jesuit Mission and just camped out in the mission yard and started seeing patients as fast as they could. They were cutting off limbs in the field . . . it was pretty chaotic when they first arrived. That’s when Jake Wood notified his father back in Michigan that they could use a second wave of team Rubicon. The team coalesced from all over the country – California, Texas, New York – and none of us know the other guys at all. We all just showed up and it’s been amazingly well organized. The team leader down here, Gary Cagle, is a medical logistics guy who worked with the U.N. He was able to put together a 501-c-3 in a matter of about four days and he raised about a quarter of a million dollars in order to bring a team down here and get the job done. So they showed up at the airport, we off-loaded all our gear and came over to the Jesuit Mission, everywhere was pitch black. They told us to throw our sleeping bags down on the ground and they’d introduce us in the morning when we could see everybody. All night long I could hear planes coming and going because the runway was so close. I could also hear babies crying, but it wasn’t until the next day that I learned that this was because the Jesuit mission is a refuge for the homeless.”
“The Jesuit Mission itself is a gorgeous old Spanish-style building, but it is unusable. It’s about to fall down and nobody can actually go in it. It’s a tragedy. Everyone is now living and cooking out in the yard. There are about 40 of us here now but there is a whole group that is leaving today, surgeons who have been here for a while and have to go home. People are coming and going all the time. But it’s moving into a different stage at this point. We are now seeing wounds that were handled by people 5-10 days ago. I just took care of a little girl, probably three years old, who had her leg amputated traumatically and we were just cleaning up and redressing her wound. Whoever handled it initially didn’t try to do a true amputation they just kind of cleaned up the wound and took the rest of the leg off. We’ve seen fractures – I just treated a guy with a lower leg, tib fib fracture that was never set, never seen by anybody. Somebody just got him some crutches and he’s been limping around with an untreated fracture ever since. We’re using cardboard and duck tape to stabilize his fracture because it’s too late; we can’t get it to set at this point. The surgeons at the local hospital operated until 10pm last night and they had another 200 cases waiting for them. There’s a lot of open fractures down here, a lot of orthopedic work.
One serious problem down here is the lack of follow-up. Some docs are putting in external fixators, but they are leaving them with nobody scheduled to follow it up. A lot of people are walking around with X-rays and medical records and hoping that at some point somebody will take the bars off their legs.
Today we drove away from Port-au-Prince and found a place to park under some trees. We’ve got two trucks out here and just set up a bunch of chairs to see people. The people have been very obedient and calm, we just have to make sure we’re not passing out food and water. We don’t see starvation but people are certainly not happy. But at the same time in Port-au-Prince people are coming back out. They can be seen sitting outside eating and drinking.”