Rubbing shoulders

Practicing medicine, on any level, means that you press up against mortality. Invariably your own mortality. What we do often merely staves off death. Sometimes in the long term. Sometimes in the very short term. I've heard people mention this before, but it's only recently that I'm beginning to understand it on a personal level.

An attempt to save a life, to care for another, is to acknowledge the brevity of that life. And the ultimate fragility. No matter what "salty dogs" may say, this...is....hard! It is perhaps easier for those of us in prehospital care. We see our patients for a brief window of time, often don't get to know them on a personal level, and their care is passed off to someone else. The tragedy comes from circumstance, the sadness of a situation. For those healthcare providers who spend more time with patients, I believe the cut of death becomes deeper. It is an emotional connection being lost as well. 

It's not just a patient that one is connected to dying that is hard though. That event forces us to acknowledge that no matter what we do, it is a temporary extension of the inevitable. 

Recently, I've moved further in probing these feelings. It's hard, it sucks....and it's also a great honor to be in that position. As with many things, polar opposites highlight each other. Exposure to death gives me more beauty in my personal life. It is an opportunity to slow down, and appreciate all the things around me that I love and enjoy. That I believe is one of the great gifts of medicine. We see the unfair suffering, sudden and chaotic passings and the slow fadings away. But in exchange we are forever reminded of how beautiful each breath we take is, and how important it is to savor the life around us.

Day 4

Today is a full, hard and fulfilling day at the clinic. There are three of us in station one, a primary tent. It is a pop-up shelter, like the one you'd find at a wedding or catered outdoor event. There's canvas walls and roof, and it seems fairly well anchored. The floor is dirt, as we're in the courtyard of the police compound. There are old, rubber and steel patio lounges that serve as patient beds. We sit on old home depot buckets. At the rear of the tent is the "pharmacy": two folding tables covered in medications (majority labeled in Spanish) that we try futilely to organize each morning. There is a rapidly dwindling supply of oral-rehydration electrolytes, cough syrup, Ibuprofun, antibiotics, antifungal/antibacterial creams, and antihypertensives. It seems we are always out of what we need most.

Joining me in the tent is TJ, and our hero of the week, Dr. C. Dr. C is a primary doc....a really really smart doc. He leads station one, and is more than patient with TJ and I as we get his input on patients.

The patients...well, there's a seemingly endless stream. They line up outside the gates hours before the sun rises. There, Haitian volunteers "triage" the patients, but they really just provide them with slips of paper with their name on it that shows their place in line. Once outside our tent, there is a second line, with a few chairs to sit in. This is were TJ and I try to scan, and pick out the sick kids. I mean, the really sick, comatose in their mother's arms sick. There's usually 3-4 of those a day.

With the help of translators, we see patients as fast as we can. There is minimal paperwork, which is nice and means we can see more people quickly--around 500 a day.

There are a few complaints that seem to permeate the entire populace. Everyone has diarrhea. A headache. A stomachache. Worms. Scabies. Especially the kids. The adults are stoic, smiling a polite smile that doesn't crack the pain in their eyes. Kids are....kids. To a point. The young ones are wonderful. They laugh, smile, or are shy and hide away in their mother's breast. Some of the older children sense what is happened, and the shock reads more clearly on their faces. One girl of about 12 starts crying when I ask her how she is today. Everyone is grateful to be seen. No one complains about the wait in line.

I find that I can't get enough of these kids, which is good because our patient population is probably 75% pediatric. Even though most people live in tents or tarp shelters, every child somehow has clean clothes. The girls wear ribbons in their hair and fathers fret over sons who have dirty hands.

As we see more and more people, the complaints through the language barrier begin to make sense. A headache, a stomachache....it's stress. Lots of stress. I don't think mental health is something that is stressed in Haiti. So it presents as these complaints. Many adults state they can't sleep. Or have nightmares. All we can do is give Benadryl, and a reassuring smile.

The kids would all be healthier if we could just make their environment cleaner. Diarrhea runs rampant due to the food. Skin infections because of the sanitation issues. Open sores and crusted, itching blisters abound. Our creams disappear quickly. Others have upper respiratory infections, sinus infections, or ear infections. We are all on edge to catch fevers in our history--everyone is worried about malaria. Many single mothers come with three or four children, all sick. They leave with armfuls of medications, and my hope that they don't get mixed up.

I know I'm rambling. I'm trying to give a sense of the day. Of the kids. I'll talk about adults tomorrow. It became my goal to see who I could pull a smile out of. Kids became easy--parents were the challenge. Sometimes, I feel like it was the best thing we did. The toughest part was knowing this was all a temporary fix to a larger problem.

I'll leave with this picture. This adorable girl blew kisses throughout her interaction with TJ.

Day 3

Smoke billows over the city nightly. Our guess is that it's trash burning, and it gives the skyline a war-zone aura. It's trash now...it was buildings. And bodies.

I'm learning that Haiti is a country of dichotomies. Every morning, a marching band raises the Haitian flag on the grounds of the presidential palace as the many people in the nearby tent city watch. Though there is no sewage system or electricity in the tent cities, last night I watched a lone garbage truck making its rounds through the streets.

We transported two patients today. One went to the ED with a rigid abdomen while another patient needed transport to University of Miami for an ortho consult on an ankle fracture. CIMO drives the ambulance for us, and we run emergent everywhere. With the heavy congestion on the roads however, it does little to help.

Working in the clinic, we've gotten a crash course on antibiotics and common infections from our peds ER doc. The patient population we are seeing is about 75% pediatric, so it's a helpful session.

The strength and compassion of the Haitians we work with continues to impress, and in an effort to equal them, TJ and I are going to try and work a 36 hour shift tomorrow, covering the night shift at the emergency department (we hear they are understaffed at night).

On a side note, our tent really stinks. I think we really stink. As hot as it is on the roof, Evans says it's too cold for him to sleep up there. I guess our living arrangements are for the best.

Day 2

Our clinical days are idyllic, compared to how it must have been right after the earthquake. The stream of patients is still unending, but there is much less trauma now. The clinic's surgical room has seen little surgery as of late. The clinic is split into three stations, sometimes four. Station one is for general treatment, housed in one of those pop-up tent shelters in the compound. Station two is primarily wound care, though also general treatment. It is in one of the buildings in the barracks. There is also a pediatric station inside the barracks, and some days there is an OB/GYN room. TJ and I spent most of our time in station one, rotating as needed through the other sites.

It's easy to lose count of how many patients we see. I saw kid after kid after kid--lots of pediatric exposure. Lots of diarrhea, malnutrition, respiratory infections, skin infections....These kiddos just can't stay healthy with the conditions they are living in. A lot of kids are showing signs of stress from the earthquake, sometimes silently crying as they sit. Perhaps the most difficult thing is knowing we are providing temporary solutions to chronic problems. Still, we treat with pedialyte, Ibuprofen, antibiotics, and anything else pertinent from the pharmacy. It is a new challenge, since most of the medications are in Spanish.

Three to four times a day TJ or I catch a nearly comatose child in line, limp in their mother's arms. These go straight to our peds ED doc.

TJ and I transport one patient via the ambulance CIMO has to the OB ward. There aren't any doctors there, and we're not sure we improved her situation. Later that night I helped the ped's doc extract chipped teeth from a three year old who fell.

My translator is Jacklin, a Haitian medical student. He's smart and compassionate--I would love to see him back in school soon, as he is the type of person Haiti needs so much right now. TJ is working with a CIMO guy named Evans. He has the interest and aptitude to be a medic, and we are trying to teach him as we go along. Really, we couldn't have done anything without these two during the week. They translated, helped us wade through situations, and gave us something to shoot for in integrity. Both have been working almost non-stop since the earthquake. Jacklin has worked with different medical teams as a translator. He always pushes for the teams to go further into IDP (internally displaced people) camps to reach those who can not reach us. Evans was in the presidential palace when it collapsed, but his sense of duty has kept him on the job through it all. He and his sisters even adopted an orphaned 15-month old after the earthquake. Evans is so proud of his new son.

The only crack in their armor is their eyes. You can see the sadness, especially when we see patients. There is the woman with her newly adopted son, trying to take care of him though she has no food or shelter to offer. The family of four, a single mother, still without shelter. The twelve year old with no one.

That night was unbearably hot in our tents, pouring sweat inside as the rains pounded outside. A few questions on my mind as I try to sleep: What is the end game in Haiti? Who rebuilds? Where has the government been? How do houses get  rebuilt? It is so important to ensure your donation money makes it to the ground here. How does this situation become something other than the status quo?

JFK-MIA-PAP

We stay the night before our departure at the Howard Johnson in Jamaica, just outside JFK. It is one of the more...colorful...hotels I've stayed in. Nonetheless, we know it will be better than the conditions coming up.

I say we, meaning my travel partner and I. Let's call him TJ. He is a close friend and paramedic as well, and has been a long-time mentor of mine. To cop a cliché, he taught me everything I know.  I'm glad to have him on the trip.

The team meets in the lobby at 0245. A freezing rain has started outside, as two shuttle vans load us and our luggage. Thirteen team members and forty bags. TJ and I alone have 200 pounds of gear among six bags and two stretchers. Even then we'll end up short on supplies.

Our team consists of a pediatric ER doc, a primary care doc, a few nurses, and TJ and myself. The docs are phenomenal, and we'll learn a lot from them.

.......................................................

Wheels down in Port au Prince at a little bit after noon. My initial impression is that of a functioning country. There is little visible damage at the airport, although roving humvees and the University of Miami field hospital in the distance are reminders to what brings us here.To my surprise, our flight is positively packed with aid workers. We are hustled into a hanger, where chaos ensues as massive amounts of baggage are unloaded.

After some orderly jostling, our bags are collected and we are herded through a cursory customs check. Outside, in the blinding sunlight, Haiti hits me. A gate separates the airport from the road, and crowded there are people looking for work, looking for people off the plane, and looking to hustle. Our driver meets us, and we begin a caravan towards the vans.

At the vans is a lesson in situational awareness. Men looking for work started arguing with the people our agency had already hired. They thronged around our team leader, a timid women with no medical background. As the team milled about, the crowd got larger and larger. People started pushing and shoving, and voices were being raised. This whole time, TJ and I were on edge, circling the crowd and listening to that fuzzy gut feeling. Some internal tipping point was reached, and we plucked our team "leader" from the crowd, shoved half the team into one van and hustled ourselves and the rest into the other. Welcome to Haiti.

As we drove into the heart of Port au Prince, the scale of destructive began to come into perspective. All around us, there are piles of rubble that used to be buildings. Those that are still standing are missing facades, or floors, or leaning dangerously. A burnt out car flashes past my view. Blocks upon blocks of tents zip by, as rhythmically as utility poles. The tents nearer the airport are bigger, and nicer--the result of USAID and the Red Cross. Nearer in the city, tents become scarce and anyone with more than one tarp has a mansion. Every yard of every house we pass has a tent. No one goes inside.

Our destination is a clinic set up inside what is left of the barracks for the Haitian special forces. The tiny compound is divided from the presidential palace by a tent city covering what used to be a lush, green park. Inside the compound, the soldiers have set up their own tent city in the courtyard. Here is were most of them live with their families. I find out that we are to camp out on the roof of the barracks--apparently it is still structurally safe...comparably. The view from the roof is devastatingly awesome. It overlooks the tent city, and the collapsing presidential palace. Destruction can be found down every street, and the view we have from one side was previously obstructed by a four story building housing the legislature. That building collapsed with many inside.

We set up tents on the flat, concrete roof. The space is shared with other groups, from Columbia, Argentina, and the US. I'm told to keep my tent zipped shut, as there are "rats the size of cats" Turns out not to be an exaggeration.

Our team is thrown into the fire immediately, as the clinic is short-staffed. TJ and I take our first patient when we intercept a doctor who is about to send a pre-ecclamptic patient to a nearby hospital. We throw here on one of the stretchers we brought and load her into a surprisingly modern ambulance owned by the special forces unit we are staying with. Inside is an old Ferno pram, the only supplies being a few angios and some old IV bags. Several translators and a police escort are tossed into the ambulance with us, and off we go.

It will become apparent during the week that anytime the ambulance goes out, it goes lights and sirens. To and from our destination. It seems silly at first, but we roll with it and soon realize it is the only way we have any hope of getting anywhere in a reasonable amount of time, considering the insane traffic congestion on the streets.

Thankfully, the patient remains stable, as our biggest challenge is just finding the hospital. It turns out the hospital is little more than some old MASH-style field tents in the area behind the presidential palace. We are directed straight to the OB ward, where we search for someone in charge. The ward is a few cots in a tent, with no staff in sight. With much translation difficulty, we discern there is no bed for our patient, or a doctor, among somnolent babies and fatigued mothers. With the help of some friendly GIs, we are directed to the ED.

The ED is, again, two field tents together with a few cots. An MD and NP, visibly burnt out, accept our patient. We transfer her over to a bloody green mesh cot that is hastily washed off as we arrive.

Leaving the ED, the smell of heat, people, and concrete fills the air. Evening has set in, and somewhere something is burning. Our work is cut out for us.

We return to the compound, as a curfew is set at dark for all aid workers in the city. Tents are pitched, and as sirens wail across the city, we settle in to our first night in Haiti.

The Return

I'm back, safe and sound from Haiti.

It was an incredible, intense week. Heartwarming moments and heartbreaking moments. Some of it was easier than I expected, while other parts were harder. Ultimately, I know that our team helped a lot of people in Port au Prince. I really couldn't have done this without everyone's generous support--thank you again.

Over the next few days/weeks I will be posting my experiences there, as I had written them on that day. So take a trip back to the recent past with me, and I will share with you my experiences on the ground in Haiti.

As I Take My Leave

*Note: I wrote this at work, and am posting at home. Now I am T-12 to NYC, although it will be a bit longer before we are on the ground in Port au Prince. *

I'm at work, though my mind is several thousand miles away. It's my last set before my journey begins, and I'm antsy. There's been so much planning, fundraising (thank you, again), packing and re-packing. Now I'm anxious to have everything begin. It's similar to hoping for a serious call or a fire at work--there's so much preparation on the back-end that we are all itching to put it to use.

In a recent interview (calm down, it was my alma mater's online publication) I was asked what I hoped to accomplish in Haiti. My answer is a little selfish, and that's to see the difference I can make in someone's life. To bring calm where there is chaos. Stability where there is uncertainty. Partially, that's what draws me to medicine. Sometimes, just sometimes, I'm able to see someone's life improved because of what I was able to do. And so I hope this trip goes. From what the other teams have reported, they have been treating somewhere in the range of 500 people a day in the clinics, so at least the odds will be on my side of succeeding!

Here are a couple tangible pictures of what you guys helped bring about. We're maxing out the airline's restrictions on what we are bringing with us weight-wise. Yes, apparently baggage restrictions still apply on humanitarian missions. We have airway kits, wound care supplies, stretchers, first-aid kits to hand out, antifungals, antibacterials, Ibuprofen, a variety of drugs for allergic reactions and chronic illnesses, syringes for oral IM medication administration and oral rehydration powders. On one hand, my heart sinks when I think that this is but a drop in the bucket as far as need goes. And to pull the cheesy charity line, on the other hand it is something. We are doing something and that will make a difference. You guys made this happen.

This is my last post until I return. I'll take lots of pictures, and lots of notes. And I'll report back. Most of all, I will attempt to convey the generosity and open-hearted kindness that I have felt from so many people. 

So that even one life breathes easier because you have lived….this is to have succeeded.