Haiti, Day Six

Day six was less about considering the condition of the people here and more about working as hard as I could. I began to realize how little time I had left and didn’t want to waste a single minute of this precious gift of being here. I have to be sure that Owen Ala, a fellow resident my year at UNM, gets credit for helping the people of Haiti. I was scheduled to be on call day six and seven back in New Mexico. Owen had some stressful things going on in his life, on top of being a busy resident. He had been on call a few unlucky weeks in a row and I asked him to add another one on top of that. It was not easy for him, but he did it for me. If he had not done that, I would have probably had to leave three days earlier to make it back in time to be on call at UNM back home. He allowed me to extend my trip by about 1/3 and those days were filled with work that needed to be done. He is directly responsible for helping the people of Haiti during this time, even though he never got on a plane. Thanks.

Dr. ____ (need to find where i wrote down his name) is a second-year resident, like me. We were able to work together for some of the time. It is interesting to know that the principles being taught are, for the most part, the same all over the world. The difference is that while he reads about some fancy fixation devices and techniques, we actually have access to use them in the states. The table in front of us was where we piled all of the donated external fixator parts we had. It felt a little like building Legos: scrounging around in a pile of parts looking for the perfect component to finish off the creation.

So many people were still streaming in with serious injuries, even now, weeks after the initial devastation. External fixator devices, as stated in an earlier post, were an essential method of treatment for long-bone fractures (tibia, femur, and others). They allow health-care workers to take care of wounds if the fracture is open (what used to be called “compound” or with bone injury and soft tissue around the fracture). A patient can even walk on a leg that has one of these contraptions in place until the bone heals completely. This is as opposed to a cast, which covers up a possibly festering wound and is not stiff enough to allow walking.

Drilling the pins into the tibia (shin bone). You can see a bunch of anesthesia equipment behind us. That’s all fine and dandy when there is electricity. A few times a day, the power would just go out. There was still light because the top two feet of the walls were open to the sunlight and we had our headlamps. However, what do you do when you’ve got a patient asleep with a machine keeping him alive? The anesthesiologist starts squeezing the bellows by hand until the power comes back. Sometimes that took hours.

Here’s the assembly of the Erector Set/Lego creation.

You can see how close the other operating table is to ours. There was a general surgery case there and the young man had peritonitis (bacterial infection in the lining of the abdominal cavity). The general surgery resident from Chicago had done his best to clean it out. The young guy was so unstable, they left him asleep under anesthesia for a few hours while we did a number of other cases a few feet away. At some point, we heard the ominous beeping, signaling that he was dropping his blood pressure and oxygen saturation. Zach Child, the gen surg resident and I discussed the case and we coded him (CPR and other last-ditch efforts) for a few minutes. He was too far gone, the infection had spread too much and we lost him. He was a young, otherwise healthy-looking man, except that now he was gone from this corner of the world so acquainted with suffering and death.

This is the final ex-fix construct. I am actually doing a research study on this unique triangular configuration I came up with that is particularly suited to emergency work in 3^rd world countries with limited resources. It uses the most common parts (regular pins, clamps and rods) and does not require x-ray imaging while being put on (which we didn’t have). It also doesn’t require the pins to all be placed precisely, as all other constructs commonly used require. The triangle can always be assembled, no matter how the pins are placed into the bone. The key benefit is that the triangle also allows us to easily adjust the alignment of the bones after the patient has gone to the other building to get x-rays to see how we did. Good alignment is the whole point of the procedure and all other constructs (except those that use expensive components that aren’t available in 3^rd world countries) are not fully adjustable in all directions and planes. Lastly, when final alignment is achieved, the construct can be made as strong or stronger than other commonly used constructs with a few finalizing modifications. Hopefully, this will be able to help someone else during the next similarly horrific disaster in some other part of the world.

Since there was such fast turnover of physicians and support staff, it was essential to write the plan for the wound care directly onto the dressing. It also served to remind me how little time I had left that I was writing dates for the following week when I would be back in my air-conditioned, clean and new hospital at UNM (month/day in case you were wondering if the dressing was to be changed in 7 months).

This is an open tibia fracture that did not receive treatment and was now 3 weeks out. It had started to heal, but the bone was still sticking out of the skin, drying up and dying. The guy was a little crazy, so his delay in presenting to the hospital was understandable since those of sound mind came in with untreated injuries weeks later also. He was going to need an operation to shave down the exposed bone and cover it with soft tissue, but I don’t know what eventually happened to him. You may think that my goal is to gross out the reader, but it’s not. You also haven’t seen the picture below, which is much worse (or better, depending on your perspective).

The ER tent sent someone up asking that someone from ortho come down to see a bad wound. I came down and pulled back the dressing to find this. There were over a hundred maggots in this woman’s serious foot wound. While it looks disturbing, she probably had the cleanest wound in all of Haiti. Her wound will probably heal in secondarily (from the inside out) better than any of the many other infected, necrotic wounds with we dealt with.

A guy in his 20s came in with a shoulder that he had dislocated 3 weeks before during he earthquake. At least that was his story. We made a few attempts to put it back in by giving him pain meds and pulling on it. When it was clear it was not going to go in, we decided to take him to the OR and open it up. That’s when we realized that he probably had this dislocation for months or years before the earthquake. We were able to get it back in place after a good deal of soft tissue dissection, but his shoulder will be far from perfect. We actually saw a lot of people who had old injuries and came in looking for help. We were glad to do what we could, but it changes our plan for intervention when the injury is chronic or acute. No big deal, we actually get the same stories in New Mexico all the time.

Tomorrow is my last day. I feel like I did when my mission in Uruguay for my church was ending, after having been there for two years. In Uruguay, I started waking up a half hour early every day to finish reading some books I wanted to finish before going home. I would walk so fast that my companions had to almost run to keep up. I can't stand not finishing all-out. Haiti made that difficult, though. We were not allowed to be out of our military compound after dark because of the very real dangers all around us. If people thought Haiti was a dangerous place to be before the earthquake, you take that same deviant sliver of society and place them in these conditions and you get a whole new level of social misfits. I would work feverishly around the hospital, but the moment when they told us the troop carrier was leaving was always too soon. I hated going back to the camp to sit around and eat and swat away mosquitoes. It was nice to recap the day with Mike and my Dad and find out what they were able to do that day, but there was so little time and so much needed to be done. If all 25 residents in our UNM program had come down and worked around the clock, there would still have been a ton left to do at the end of our time.

Haiti, Day Five

The front of the County General Hospital. No one uses this, or any of the multi-story buildings. The sign for the Place even collapsed. Next to me is Ben, who spoke French (Creole is a form of French, so he could translate and most people understood him great) AND he has OR experience so he was a huge help. He is currently pre-med and will make an awesome doc.

This is across the street from the County General Hospital. A building completely flattened. The medical school and the nursing school look like this and it is creepy to know how many students are still inside.

Between making my Haitian “Schindler’s List” and getting most of the acute things taken care of between the few orthopaedic surgeons at the U of Miami tent hospital, I felt that I could now leave there and get the chance to see another very different situation. Another resident from our program, Zach Child, happened to be in Haiti on a longer trip, working at another hospital and some from our Utah Hospital Task Force group had connected with him and realized we know each other. So, Thursday I decided to head over to the Haitian University Hospital, but for clarity, we’ll just call it the County General Hospital since that’s what it felt like. If I thought conditions were bad at the U Miami tent hospital, I had no idea how bad they could really be.

The general hospital is/was made out of buildings, but no Haitians trust buildings anymore. It’s no surprise since, at the general hospital, the medical school building collapsed, killing about 57 of the 60 students. To get to the supply area, we had to walk by the nursing school building which exuded the odor of the 80 nursing students who died when it came down. They had just barely begun to pull bodies out since the debris from the collapse was so massive.

So, the Haitian general hospital also became a tent hospital with only the stout, one-story buildings still in use, one of which was the OR building. The OR is so different from anything I could have ever imagined as being appropriate for surgery. This may look sterile, but you have to remember that we are in a completely open room, where flies can just fly in and roost right in the middle of an open incision. Just imagine having to do a surgery in a bathroom stall that hasn't been cleaned, and it is 100 degrees with 98% humidity, and there is someone close enough to touch your backsides doing another surgery right next to you (and then two more like that around a small divider, but still connected).

Operating with me in the above pic is Dr. ____ from Nepal, who is one amazing gentleman. He didn't come with any organized groups. He just saw the news about Haiti, bought a plane ticket and stayed in a humble hotel room while here. He was perfect for this since he had so much experience with 3rd world orthopaedics with limited resources. Very good hands and practical decision-making. He didn't have a military escort like our group or Zach's. He just got on a Tap-Tap or rode in a taxi. Truly someone who gave much and came from afar with no fanfare.The world needs more like him.

Here, we're doing a through-knee amputation. This man had previously had a below knee amputation (BKA) likley due to severe leg/foot injuries. However, his wound was still open weeks after the initial surgery. A BKA is a very functional level for amputation if one obtains a good prosthetic, but a healed through-knee is better than a non-healed and open BKA. So, here we are revising the amputation to this higher level.

You can see an oscillating fan in the picture above. Heaven is when that fan blows its sweet salvation across your part of the room for a second, before moving on to the next person sweating in a sterile/impermeable oven...i mean gown.

Haiti, Day Four

Walking around the outside of the U of Miami Satellite tent hospital. First you see the ER (some cots below a tarp), then a random dude carrying a full bedpan, then the adult tent, and at the end, the radiology department, er, I mean, cot.

The biggest problem in Haiti is logistics. There are facilities, supplies, service-workers, and injured people, but you only get at most three of these in any given place at once. It’s kind of like the engineer’s saying: “Good, fast, cheap: Pick any two.” Therefore, one thing I realized was that we had to get the patients where the appropriate facilities and supplies were.

Many of the patients in our cots at U of Miami Hospital were either so seriously injured that we couldn’t even begin to fix their problems (pelvic and spine fractures) or those that were closed injuries that we didn’t want to open up to put plates and screws into (because then it’s just asking to get infected). So I started gathering and making lists from all of the different ortho and neuro surgeons.

However, only a small number of patients could go to these other facilities for higher levels of care, such as the USS Comfort, a Navy surgical ship sitting out in the port, and other smaller surgery centers run by Americans with clean ORs. Gathering the lists and deciding which patients got to leave our humble tents to go to cleaner, air-conditioned, well-provisioned facilities, I couldn’t help but thinking about that scene from Schindler’s List where they say “The list is good, the list is life!”

You can see the USS Comfort Navy Hospital Ship way off in the harbor to the right. If they could just get their pier and port up and running again, this country would have a chance, since it is the main vein of all commerce in Haiti.

One of the pediatric surgeons saw me making my list and started begging me to put a certain girl on it that she had become attached to. I went ahead and put her on, but to do it, I had to take someone else off. Looking through my carefully selected, short list of those who needed to go the most, I couldn’t see anyone who obviously didn’t need to go. For me, it was going to be random to take someone off the list, but for that person, it may have been the difference between life and death, or at least the difference between a good quality of life and chronic pain and limitations until the day they die.

Haiti, Day Three

Here’s how a day went in Haiti: Climb down the ladder from the huge troop carrier that the 82nd Airborne transported us in from the hospital to the camp. It was usually dark, but sometimes if it was still light when we got back, I got the luxury of choosing whether or not I was going to either take a “shower” or eat a self-heating MRE meal while sitting on an upside down bucket without the need for a headlamp. Usually, though, I got to do both of those activities with a slowly dying headlamp (there were no spare batteries). The benefit of a dim headlamp was that it didn’t attract as many malaria-laden mosquitoes. After the “shower” I would wash my underwear, socks and scrubs in a bucket, using Irish Spring bar soap. That way I could be sure I would smell wonderfully all day long. Those clothes were for the day after the next since they wouldn’t be dry in the morning.

This kind of destruction was commonplace on every street.

Haitians going about their daily business, amidst the destruction.

There was a little bit of time to hang out with Dad and Mike and talk about what each one of us was doing. I usually didn’t work where they were, since there were usually 5-10 different groups doing different things out of the 120 members of the group. A few nights I was able to call Bri. Surprisingly, my talk time was limited by running down the battery on my dad’s phone (I didn’t have an international plan) rather than how much it was costing (since the minutes were unlimited for service workers in Haiti). If anyone knows my Dad, then you’ll understand and appreciate the paradoxical reasoning here. He was more concerned about going to bed with a 100% symbol on his iPhone and the fact that someone would have to babysit the phone over by the generator while it charged back up after talking (can’t leave phone on charger all night when 120 people are trying to charge phones off of just a few plugs). Heaven forbid my dad hits the sleeping bag (yes, he did actually sleep on the ground, in a sleeping bag!) with a 98% showing on the iPhone.

This wasn't even the dirtiest sewer/waterway. Some were so full of trash that the water flowed UNDER the filth.

After brushing the teeth and laying out the clothes I washed the two days before for their final attempt at drying in the 97% humidity, I hit the sack. Everyone in the camp was awoken by the roosters. Too bad the time they chose to crow at 11:00… and at 1:30… and at 3:30… and about 10 other times during the night. Loved it.

I really knew it was time to get up when I heard the troop carrier trucks start up their diesels and come over by our tents. I was ready in about 2 minutes since all I had to do was put on my “dried” freshly-Irish-Springed clothes, brush my teeth, and throw a couple of energy bars into my day pack – one for breakfast, one for lunch.

Hard to see well, but that tilted tower is a newly constructed building that just tipped over. So much loss of capital and work. I heard that it was not lack of metal reinforcement, but adding too much sand and stretching the materials too far that caused the cement to just liquefy when the quake hit.

We could beat traffic if we left early. One time we left later than our usual 6:30 am and sat for an hour in the food-market area in a complete log jam to complete an otherwise 15-minute trip. Driving through Port-Au-Prince your senses are on complete overload. There is destruction everywhere, the streets are absolutely filled with trash, yet people are still trying to go about their daily business. Speaking of trash, I realized that if your life’s work was to make the streets of a city as disgustingly filthy and unsanitary as possible, you could not make any street any dirtier than most streets in downtown PaP. I saw one garbage truck during the entire week down there. It gave the impression of an ant carrying away a piece of straw, thinking it eventually is going to be able to move the whole hay bail.

This trash in the street is actually one of the cleaner piles I saw down there.

I’ve already talked about what I was doing at the hospital, but I’ll go into more detail about one of the aspects of my work that had a big impact on me tomorrow.

Haiti, Day Two

Something I could actually do completely on my own: casting and splinting

The orthopaedic surgeon in our group had already been there for a couple of days working in a tent hospital. It is a satellite of the University of Miami, run completely by Americans. They were apparently in the process of building an actual hospital, but since the earthquake, had set up a four-tent hospital with about 250 “beds” (really, cots). The ER is 8 cots under a tarp outside. The OR is just the end of the Peds tent and the OR beds are nailed together pallets. The C-Arm live-xray machine worked for maybe 5 minutes before it would overheat. Central sterile processing consisted of a few picnic tables with a couple of people who would clean and soak the instruments in sterilant.

The OR

The video I'll put up tomorrow shows a walk-through and at the end, you see the “Radiology Department” which was a guy running a digital x-ray machine next to a cot. There were no printed x-rays and if you wanted to see anyone’s films, you had to wait until they were done and look at them on a little screen.

The pediatrics tent. You'll see me pull back a tarp: that's the separation between patient care area and the supposedly sterile environment of the OR. In an emergency situation, you make do with what you have...

Getting to the hospital was when I realized how big the medical needs are in Haiti. And that’s before I even went to the even more busy Haitian-run hospital, but that’s not until Thursday. Someone said they heard on CNN that there are too many volunteer doctors in Haiti. I have no idea where anyone would get that idea. They must have absolutely no experience in medicine or surgery, because no matter how many docs there are or were at that time, in that particular room where that person was, they will NEVER have too many doctors and ancillary health care workers in Haiti. Even if someone had an operation within days after the quake, that’s not the end of it. In these conditions, clean surgical wounds get infected almost inevitably. We had the luxury of having access to “wound vacs” which are small bedside machines that attach to sealed, covered foam sucking the nasty out of wounds to help them to pull together. With the number of infections, these things were being used everywhere. These wound vacs need to be changed every few days in the OR. Besides that, infected wounds were coming in daily. Many needed amputations and subsequent revision surgeries.

Half of the operating room. Behind it, over the blue dividers is the three beds which made up the ICU.

With my relatively lower level of experience, I wasn’t there to do crazy-complicated surgeries on my own. I was there to do what I know how to do and serve wherever I could help. I was able to do some surgeries on my own, but for the more complicated stuff, I was helping other Attending-level surgeons. I found a niche doing much the same job that I do at UNM which is to run around the whole place and give information to generalists about treatment decision-making, putting on casts and splints, evaluating wounds, and helping to triage and prioritize in the ER. I didn’t go to Haiti to have a different experience, necessarily. I went to help, and if that meant that I did almost the same thing that I do at UNM currently, that’s where I wanted to be. Even though I wasn’t always operating, I was always super-busy and helping to keep the huge volume flowing.

The other half of the OR. You can see the c-arm machine which barely worked.

Since the OR was in the Peds tent, I got to walk by the kids often. It was heartbreaking to see so many cute little kids with external fixators on their fractures. External fixators (ex-fix, for short) are basically pencil-thick pins that go through the skin and into the bone and are then connected like Lincoln Logs to keep the bone lined up. In the states, they’re used as a temporizing measure when wounds are too dirty to fix with plates or rods or the patient is too unstable to tolerate a bigger surgery. In third-world countries, they’re often used as the definitive treatment since they are quick and easy to put on, adjustable, have lower infection risk, and many of the parts are reusable.

Sterile "central supply." In third world countries, most stuff gets reused. In the States, that makes you lose your license and you go to jail.

It’s hard enough to see kids in the States with great resources who are suffering, and it’s even harder to see it in Haiti where the resources are spread so thin. The way I get through that kind of thing is to remember that I didn’t cause the hurt they are suffering from, but I can possibly be someone who can bring them out of that hurt and help them to get better. It was especially hard when one of the girls suddenly stopped breathing after she had her dressing changed under sedation. I wasn’t involved in her care, but walked by when they called the code and started doing chest compressions. She wasn’t even one of the really sick kids, but it reminded me how close to the edge so many Haitians are and that the quake pushed so many to that tipping point, and then over.

Life expectancy in Haiti is mid 40’s. Death is a part of their life. I even heard that as opposed to the typical western toast “To Life,” Haitians will often toast “To Death.” And if death wasn’t already at the front of their consciousness, it has been thrust there by the quake for an entire generation of Haitians.

Haiti, Day One

So many people have asked about Haiti and I have wanted to get it all in writing, so I thought I would try to post a blog each day this week and recount each day of the one week I was in Haiti. So, now, offset by two weeks, here's what happened and what I experienced.
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About four weeks ago, my dad was asked by a friend he worked with at the White House (in the 70’s) to help organize a trip to Haiti. It was called the Utah Hospital Task Force and consisted of medical professionals, construction specialists and missionaries who had served in Haiti to work as translators and cultural ambassadors. All going would be members of the LDS (Mormon) Church and many were from Utah. I was planning on taking a vacation in February anyway, and it seemed like a perfect alternative to the usual relaxing time off. Instead of resting and recuperating, I would get to do something much more worthwhile. It was a rare opportunity to serve alongside my Dad and brother, Mike. Mike is a police officer in San Jose, CA, and would be helping with security for our group.

Politically, I'm not a fan of the UN, but I sure was grateful for their free flight to get from Santo Domingo to Port Au Prince.

It didn’t look like it was going to work out since they were going for 3 weeks and it is completely impossible to be gone for even one hour past the allotted time off during residency, especially since I am one of the junior residents and lower on the totem pole. The chartered plane left without me on it. However, after the group was there for two days, they figured out a way I could go for only a week.

On such short notice, it was very hard to figure out how to organize coverage for my responsibilities and I was not going to be able to go. However, my fellow residents rallied to help me out and were able to cover everything. Special thanks to Owen Ala for covering the weekend call (a HUGE job) after calling from Haiti to ask him. It was very last minute and he sacrificed a lot to work that entire weekend for me.

It was a huge scramble to pack and get everything ready on such short notice. I didn’t have everything together since I though it was going to be impossible to go. However, the plan my dad worked out was to have me fly a Delta flight to Santo Domingo, Dominican Republic, then take a United Nations 7-seater jumper, specifically for flying in medical professionals, over to Port Au Prince, Haiti.

Surprisingly, we were able to find a flight to the DR relatively cheap ($350!) for only having a few hours notice. I threw everything I thought I would need into an internal frame pack, prescribed myself a couple of needed vaccinations and anti-malaria pills. I barely even made the flight and they luckily held it 4 minutes just for little old me.

The flight to Santo Domingo was uneventful, aside from finally getting time to self-administer my two vaccinations in an airport bathroom. I’m sure that would have looked suspicious to anyone who observed not knowing what I was really doing!

In Santo Domingo, I noticed how nice everything was. I had obviously never been there and I thought it would be similar to Haiti since they share the island. Everything seemed to be working as usual in the country. I took a taxi to another smaller airport 30 minutes away and felt comfortable speaking Spanish, knowing that soon that comfort would be completely gone. I asked the taxi driver why nothing of such magnitude happens in the DR, but happens so often in Haiti. He said he didn’t know why, but it’s obvious they at least have very bad luck. He also talked about how maybe their government, which he thinks is very corrupt, has been cheating the citizens of what they need to be protected from such disasters.

At the smaller airport, I waited four hours and made sure my name was on the manifest for the United Nations free flight. I had emailed them 24 hours before and was relieved to see my name on a white board thousands of miles from home. A small comfort among so much uncertainty and flying by the seat of my pants, literally.

It was an experience in itself to fly a tiny plane over the island nations of the DR and Haiti before arriving at Port Au Prince. It is beautiful country and there is no visible reason from high up in the air as to why one half of this island is seemingly so cursed and the other so prosperous and stable.

The second big relief of the day was to see my Dad and an old friend of Bri’s (small world) Dave Studdert waiting for me when I got off the little UN plane in Port Au Prince, Haiti. Never in a million years did I think I was going to be there, for any reason, let alone to try to help with what little orthopaedic surgery knowledge I have at this time of so much need.

You can see the trucks the 82nd Airborne ferried us around in behind our tents. It was nice to be sitting at about 8 feet off the street, making us difficult targets for random acts of anything.

We took a Tap-Tap (tiny pickup truck with benches bolted to the sides of the bed) 4 miles to the camp. The camp where we stayed was a converted soccer field that happened to have a wall the entire way around it. That made it much safer, and the reason it was chosen to be one of the outposts for the 82^nd Airborne. We were lucky to be able to be guests in their camp and enjoy their security and transport trucks.

A panoramic of the entire camp. The military has the left side with the large tents. We had all the small tents with one larger supply tent. This camp was first built by an Israeli medical group that came completely self-contained. They were known as having done a lot of good in a short period 5of time.

By the time I arrived, the day was winding down, so I was not able to do anything productive besides set up my tent and bust out an MRE (the first of many). There are good MREs and there are bad MREs. We had the bad ones. Nevertheless, it was easy to be grateful to have any food at all when so many around you were suffering in so many ways.

One thing I noticed when we drove through the city was that there were not just people sitting around with their hands out, waiting for someone to hand them something to eat or drink. People were going about their daily business. Sure, every single building was deserted since few Haitians feel comfortable inside any kind of building at all and about one third of buildings were completely destroyed, one third were cracked and precarious, and the last third were just empty from lack of trust of the people. Besides the fact that few buildings had people in them, it seemed like people were still living life. If they sold fruit in the street, they were out selling their fruit. If they were the guy who fixes flat moped tires, they were doing their thing. People still tried to keep things going amidst the rubble and occasional stench of decaying bodies.

Those black water barrels were our wonderful "showers." It was basically a spigot at about waist level with a trickle you could clean yourself with. No matter how unpleasant that sounds, you would be amazed at how refreshed you feel after one of these showers compared to the sticky, sweaty, dirty tired feeling you've been working up all day.

One thing none of my pictures will convey is how hot it is there. It’s hard to put yourself in that state of mind since it has been so cold here lately, but the heat and humidity are crippling. More about that later. Just remember to insert the caption “we were uncomfortably hot and nasty sweaty, and this is what we were doing...” in front of every picture I post.

If I am successful, I will do a post each day this week and try to parallel each day there. I am trying to catch up in many ways with my residency responsibilities and make up for time taken off, so I may just have to end up getting very little sleep this week. Not that this would be anything out of the ordinary.