Final Thoughts

It's been almost a week since I've returned from Port-au-Prince, and I've had a bit of time to reflect on my time there, as well as all of the people I met and interacted with while I was there. As I've said, before I left I was a bit resistant to the idea of writing this blog at all. But now that I’m back, and I can read over what I wrote when I was in the middle of it, I’m really happy I did it.

As the purpose of this chronicle was to try to convey to people living here what things are like in Haiti, I hope I was able to get across what life is like for the people who come to the University Hospital for care. I also hope I was able to do this without putting any of the aid workers in the limelight. Often the reports we are shown from news organizations focus on either devastation and suffering, or on individual relief workers there to help. What I tried to convey here was neither of those things in isolation. I may have given an example or two of each, but I did that to provide context for what was happening every day in the lives of the people of Port-au-Prince.

I don't claim to have any sort of comprehensive knowledge about Haiti in general, or even about Port-au-Prince outside of what I've seen. My experience there was very limited. What I saw of Port-au-Prince consisted of the drive to and from the airport, and the 4 minutes of video in my last post. What I do know is that just about every Haitian I met--patient, family member, translator, hospital staff, or stranger on an airplane--was friendly, patient, caring, and amazingly appreciative. And all of this in the face of everything they face on a daily basis.

When I think about all that I saw there, both medical and otherwise, I simply couldn’t have imagined what I was getting myself into. The challenges (emotional and physical) were easily the toughest I've ever faced, and the learning curve for practicing in that environment was essentially vertical. In the end though, I’m unbelievably happy I did it, and would do it again in a second.

I think the last thing I should do is thank all of you for your support and kind words over the past few weeks. Thank you also for the concern and caring you've shown toward the people of Haiti. If any of you are considering volunteering or donating, please don't hesitate to contact me. I'll do my best to put you in contact with someone who can help you get to where you need to go.

Thank you again.

Frank
fpetruzella@yahoo.com

Port-au-Prince in 4:30

For one of my last posts in Haiti, I thought I'd give you a video look at the drive from the hospital to the hotel in which we're staying. It may give you a better sense of what things look like here as compared to a bunch of still photos. My camera only records a max of 3 minutes at a time, so the clip is in 2 parts.

Differences

After almost 2 weeks I’ve gotten past the shock of the conditions here, and I think I can try to describe to all of you who are familiar with US emergency departments the difference between here and there.

The way I see it, there are 4 main differences between this ED and any I've seen in the States. The first is obvious. The supplies and access to medications/tests/consultants are always inadequate and ever changing.

The second is the utter lack of privacy. Physical exams, procedures, resuscitations, births and deaths happen right in front of everyone else. Patients often have to share bedpans.

The third difference is one that took me a while to notice. With the chaos that is the Haitian ED constantly coming at me, it took me a good 4 or 5 days to realize that there's essentially no service other than physical medicine that's provided. What I mean by that is that there is no social worker, there's no psychiatrist, there's no patient meals, no one helps grieving families. The mother that comes with her dying child may well leave with her dead child. The patient who hasn't eaten in 2 days won't eat during his stay in the ED (sometimes 3-4 days) unless a family member brings food from home or one of us gives him a Powerbar or some beef jerky. I don’t know if these services were around before the quake, but hopefully the organizations that are here helping out will make sure that they are in place before we all leave.

The last difference is the acuity of the patients. So many patients are seen, treated and discharged from triage that the ones who make it into the ED are all amazingly sick. We’re averaging 4-6 deaths per day in the ED, with another one or two per day who are beyond help by the time the even reach triage.

An example of how acutely ill everyone is: last week we delivered a baby first thing in the morning on a day shift (as I described in an earlier post). Back home if I delivered a baby in the ED I would be thinking about it and talking about it for weeks (if not months). But here, I completely forgot it happened at all until the next day. When someone asked me if I had seen anything interesting at the end of my shift that day, delivering a baby didn’t even make the short list.

Don’t get me wrong--I very much enjoy taking care of critically ill people (it’s one of the main reasons I work in emergency medicine), but working essentially every day seeing only the sickest of sick in this environment is one of the most challenging things I’ve ever had to do. That being said, at the end of almost every shift I’ve worked here, I can objectively look back on the patients and families that I took care of and feel absolutely certain that had we not been here, most of these people would not be around to see the end of the day. And while that certainly doesn’t make up for the patients we couldn’t help, it does give me a reason to come back tomorrow.

　

I was in the van on the way back home today after a night shift when I noticed a building across from the hospital that I had taken a picture of on the day of my first shift. I was able to get a picture from the van today as well. It's kind of hard to believe what's happened in 8 days--without any more aftershocks. It's no wonder people are worried about moving back inside for the rainy season.

Yesterday was a good day. It started with the delivery of a beautiful baby girl about 1 and a half minutes after I walked into the ED at 7AM. I wish I could take credit for delivering her, but it was Mom’s sixth baby, so all we really did was catch. Mom and baby did great, and about 3 hours after she delivered, Mom called someone over to let them know she was leaving. She had 5 other kids waiting on her, so it was time to go. I hope she didn’t have to walk home.

It was also a good day for another reason. Today was the day that the medical ICU moved out of tents and indoors. Here are some before and after pictures of the ICU.

We no longer have to worry about the river that flows through the tents when it rains. It used to be a race to pick up all of the power strips that run the lights, fans, and the occasional ventilator off of the ground before the river engulfed them. Now, the patients are protected from the elements (including the heat--it feels about 15 degrees cooler in here than it does in the tents).

One of the interpreters told me that he was very nervous being inside again. His house was only minimally damaged in the earthquake, but he still prefers to live in a tent for fear that it will collapse when he’s in it. It will be interesting to see how the patients and families react to being inside 24 hours a day.

Perspective

I had a bit of a rough day yesterday. I felt that I was unable to help anyone adequately. Nothing in particular seemed to precipitate it, it was just the constant knowledge that if I could take care of these patients in a hospital in the States, I would either be able to do a better job for them, or in some cases be able to do something for them. I guess I was getting tired of not having the medication I needed, and settling for a second, less effective choice, or picking through a pile of instruments looking for the "cleanest" ones so I could sew someone's facial laceration. It was causing an oppressive feeling of hopelessness and impotence that was interfering with what I was doing.

I happened to mention this to Pierre--one of the interpreters that works with us. He's affectionately referred to as Little Pierre or Petit Pierre (this is to distinguish him from Big (Grand) Pierre and Pierre Pierre), and he is an amazing kid of about 17 years old who taught himself English by getting his hands on a grammar/vocabulary book when he was 9 years old. He always has a smile, and is always trying to improve/show off his vocablulary (for example, last night there were 3 people trying to leave the hospital by walking out an alleyway that ends in a wall--Little Pierre looked at me and said "If they go that way, they will go in vain."), and is one of my favorite people to work with here.

I told him that I was feeling a bit sad that I couldn't help more people.

"This is true Dr. Frank, but you do help so many." was his response.

"But if I were taking care of them in my hospital, I could do so much more. It is very frustrating."

To this he replied, "In Creole we have a saying, 'Bay piti pa chich'. It means that just because you give a little doesn't mean you're stingy. You give what you can--no more."

These are amazing people.

Hospital

I've been trying to sort out how best to give you a tour of the hopsital facilities. What I really need is an aerial view as an overview. I haven't tried, but perhaps Google maps has a view that will at least give you an idea of what the complex used to be. The hospital isn't designed like an American hospital. Rather than having one or two large buildings with many large departments within the buildings, this is a sprawling walled complex with different 1-3 story buildings housing different departments and services. I have no idea what it felt like before the quake, but now it feels like a field hospital, with most of daily life occurring outdoors. As you can see from the map, many of the structures are inhabitable (red buildings are destroyed, grey are OK, and beige are tents). Among the buildings destroyed were the lab, the pediatrics buildings, OB/GYN buildings, outpatient surgery center, church, and the nursing school building. About 70 nurses and students were killed when that building collapsed. Most medical care happens in tents set up in the middle of the streeets of the compound.

For this post I'll focus on the ED, as it's the place that I currently have the most pictures of. The ED (where I spend most of my time) is made up of 2 main tents and one "observation" tent. We're essentially a self-sufficient unit, with our own pharmacy, dedicated interpreters, and security. For the most part it functions pretty much like any ED, with a triage area, a resuscitation area, and regular beds. Here is our triage area and waiting area. About 60 to 70 percent of our patients never make it past here. The nurses out here sew lacerations, splint broken bones and write prescriptions for medications for most of our patients. (At one point I had a suture clinic going teaching 3 nurses at once how to stitch on three different patients).

Once the patients make it back from triage, they are put into either Tent 1 or Tent 2. There's no difference in acuity between these tents, but we try to put kids and obstetrics into one tent, and the rest into the other tent. Here is Tent 1. I'm standing directly in the spot where we reduced the dislocated hip the other day. On the right is our supply area, and on the left are obviously the patient beds. Often family members will sleep on the ground below the beds.

Tent 2 has a similar set up, as you can see below, but also has our "pharmacy".

I think the pictures adequately show what the physical situation is like. What the photos cannot covey, however, is the smell. As we are in tents, there are no bathrooms. There is also an overall lack of bed pans and emesis basins. Combine that with daily temperatures of 105 degrees inside the tents, and you get the idea.

I’ll post a brief tour of the hospital later today--I don’t have time to wrestle with the pictures before breakfast. I just thought I’d post a little note that I’m sure most of my medical friends (and many of you non-medical folks) will find a bit hard to believe. This is a picture of us outside in the 5 or so feet that separate the two tents of the Emergency Department.

What we are doing outside, on the ground, without a monitor, is performing sedation with Propofol to relocate a dislocated hip. The reason we’re outside is that this was the only place we could find both the space and the light to do the procedure. This poor gentleman was in a car accident and fractured/dislocated his hip. One ER doc, one ex-Green Beret paramedic, one ER nurse and I served as the orthopedics/sedation team. The patient did great, and recovered (also sans monitor) to be discharged home on crutches to come back for orthopedic surgery tomorrow.

Overnight

Forgive me if this post isn’t too coherent--I worked overnight last night from 6PM to 7:30AM. I was working in the ED, as well as covering 25 Pediatric ICU beds, 20 Pediatric step down beds, 10 NICU beds, 15 patients in the malnutrition ward, and 20 patients in the adolescent ward. I’m a bit too spent to try to mess with pictures, so I’ll give you a verbal tour of the hospital, and follow it with pictures later. For those of you who’ve worked internationally this will not likely be a surprise, but this is my first medical trip abroad, so it’s all new to me.

I’m not really sure how to describe what exactly I do here. It is so far removed from anything that resembles medicine that I’ve practiced in the past that I often feel like I’ve had no training at all. Last night I almost delivered a child in the street (which would have been the 4^th this week) because there were no physicians in the maternity ward. Not to worry though--they’ll be back on Monday.

In the ED, the things I see regularly here have only been exotic names to me back home--malaria, polio, typhoid fever, tetanus. In the States, these would be taken care of by a team of infectious disease specialists, diagnosed with thousands of dollars worth of tests, and treated carefully with hospitalization and expensive medications. Here it’s me, my WHO handbook, and whatever medications that we currently have in the ED. I sometimes have to find someone who can read German or Italian to find out what medication I’m looking at.

The inpatient “wards” are woefully understaffed and undersupplied, often with one Haitian resident and one Haitian nurse taking care of all 90 inpatients in pediatrics for 12 hours at a time. Xrays are available, but only if the patient is accompanied by a non-Haitian (otherwise it could take all day just to have the Xray taken). I have been here 4 days, and have only seen the results from one blood test. You can order whatever you’d like, but you will likely be long gone by the time the labs come back. I know 3 volunteers here who have donated blood directly to their patients, as that was the only way they were going to get blood. Last night I was informed that the ICU I was covering had run out of oxygen. The ICU was out of oxygen. The absurdity of these words was completely lost on my Creole interpreter (a third year medical student). It was just a fact, like “It looks like it’s going to rain tonight“.

I’ve been told by at least 3 Haitians that this is the best care they’ve ever had.

While it’s all a bit overwhelming, I don’t want to give the impression that our efforts are futile or useless. We can’t do everything, but we can and do help literally hundreds of patients every day. The volunteers are a fantastic group of people, both those with my organization, as well as those with the other NGOs that I’ve met here. They work tirelessly to make the best of what they have, sharing supplies, meds, expertise, humor, and food to make life a little easier for these people.

I’m off to eat. More tomorrow…

Arrival

Hello all.


I made it. The trip itself was pretty uneventful, with the exception of PaP airport. I've never seen such a madhouse. Our IMC contact met us on time, and herded us with the demeanor of a Marine drill instructor to a waiting bus outside. Along the way was a gauntlet of shouting, shoving PaP residents trying to convince me (only occasionally in English) that what I really wanted was a taxi, or for someone to carry my bags, or to buy a painting, etc. But our IMC man was relentless, and we ultimately made it out of the fray and into the bus.


I took some pics from the bus as we drove, some of which I'm putting up here. PaP is a dangerous enough place that we're not allowed anywhere other than the hospital and the hotel, so all of my pictures of PaP will be from a bus window, and will be of parts of the city less affected by the quake.




















As you can hopefully see from the pictures (especially those of the presidential palace), the force of the quake, and the devastation caused is a bit breathtaking, and makes you want to record it so others can see it. But when you focus on the foreground and see the people standing in the street because they have nowhere else to go, you realize that that pile of rubble you've just photographed was once where they lived, ate, laughed, watched their children walk for the first time, etc. I've discovered that I could never be a photojournalist. Taking photos of someone else's tragedy leaves me with a lingering feeling of exploitation that I don't particularly care for. That being said, if the pupose of this blog is to show you what it's like, and inspire you to help, I'll do the best I can.

Next time I'll give you a tour of the hospital.

f

Disclaimer

Welcome. I feel like I should state up front that I have a bit of an aversion to blogs in general. There is a sort of narcissistic exhibitionism associated with the whole concept of blogging that isn't quite my speed. That being said, here I am.

So why am I doing this? It wasn't my idea. When people find out I'm going to Haiti, a surprisingly large number tell me that I should blog while I'm there. I figure if they are interested, and I can show them what I see, perhaps some of them (you) will end up going as well.

I'll try to regularly update this with text and pics, but who knows what my time and/or resources will be like there. Hopefully there will be many more posts.

Two days until I leave...