Tuesday, March 2, 2010

And then there is Haiti

Four days after returning from Burundi I am heading to Haiti with a group of 30 other health caregivers (doctors, nurses, etc) from Flagstaff. We arrive at night at the University of Miami/Medishare large tented field hospital situated alongside the Port-au-Prince airport runway for a week stay. It is hot and humid and it remains hot and humid, day and night
The first day I find out I am assigned a 12 hour night shift in ICU, so in order to pass the daytime hours and be useful, I go and work in the supply tent, trying to sort through the mountains of donated supplies (which is a whole other story…lessons need to be given to people and institutions who donate) for several hours until I get too hot and decide it is perhaps best if I cool off and try to get some sleep before I have to stay up all night. I am less than successful at the sleep part and head to the Pediatric/OR/ICU tent at 7pm to start my shift. Fortunately I am working with a real ICU nurse, Kristi, so all is not lost (I can’t remember how many years it has been since I last worked ICU). We have 4 patients, one on a ventilator (with a trach), two also with tracheotomies, and one with a closed head injury who has to be restrained (soft)and his bed is on the floor because he is so restless. Incredibly it is freezing cold in the ICU.
We spend much of the night suctioning the trachs and trying to keep the man with the closed head injury calm and keep him from pulling out his IVs, at which we fail. We get a pediatrician to start an IV in his foot and finally get him somewhat settled. By about 4 am I am struggling but the cold helps me stay awake.
I try sleeping during the day but have the opportunity to go out into the city at 10am so get little sleep. . My brief 2 hour sojourn out into the city reveals a mess, I really have no words but controlled chaos, is perhaps the best way I see it in my mind. It is apparent that even before the earthquake, things would have been tough in Haiti and especially Port au Prince, so overpopulated but certainly functional to some degree. But now….one building will be completely intact on a street, the next one absolutely leveled to the ground, nothing but a pile of dust and bricks. In some places the sickly sweet smell of human remains hangs in the air. It seems that anywhere there’s open, flat land in Port-au-Prince it is covered in makeshift tent cities, which are huge, beyond comprehension …shelters cobbled together from whatever people could find on the street. However I am so impressed with the Haitians resiliency. To see people moving about trying to establish some semblance of normalcy is inspiring, traffic fills the streets, the street vendors are out in force, and clean up efforts are very apparent. From big rubble moving machines to individuals with shovels….I observe one man with a hand saw cutting rebar!!!!! You have no idea how much twisted mangled rebar there is….infinite…thus mindboggling, yet there he is diligently sawing away.

I return and try again unsuccessfully to sleep, (the heat being one factor, the noise being another in a tent with about 400 volunteers) because I have again been awarded the night shift, this time in the adult ward that houses approximately 180 patients give or take a few. It is hot in the tent. I am assigned about 25 patients, although I’m not really sure, and have a hard time keeping them straight. They are a mix, of amputees, broken bones with external fixators, diabetics with ulcerated wounds, a 32 week pregnant woman experiencing preterm labor, a post op abdominal surgery pt...etc. Fortunately their charts remain on their beds (cots) so I am constantly referring to their charts mostly to see what meds they get and when. I have a translator come with me and I go down the line and have him introduce me to each patient and ask them if they need anything. Most want pain medication and something for sleep. I go to the “pharmacy” which is at the front of the ward, a simple row of tables with some shelves behind loaded with medications, fortunately in categories, and for a few hours it is manned by a pharmacist and so I learn where what is so that when he heads to bed I can get the medications I need for my patients, myself. I work nights in this ward for the rest of my stay in Haiti, with me being the charge nurse for the last two nights. Getting around in the ward is tricky. The cots are in long rows , but are close together with a narrow space in between each one, and at night that space is filled with one and often two sleeping family members, lying usually on a piece of cardboard, or sleeping in chair. It’s hard not to just let your heart break. The patients and the families are wonderful, gracious and thankful, and it seems apparent that they don’t really get just how sick and injured some of them are, which perhaps on some level is a blessing. They just are doing the best that they can, and so….so do I. I work with a few of the Haitians translators who are amazing, such willing good kind smart people with hearts of gold, so helpful, so patient, with the patients, ah yes.... and with me. I can’t thank them enough and even though I give them some money when I leave, I certainly feel as though it is hardly sufficient.
My last night is the toughest. I am given the resonsibility of a young man, Jeremy (30 y.o, married with a 2 y.o. son) who is dying(advanced leukemia ,TB, ALL), and we (the docs on call and I) make him as comfortable as possible in one of the outside isolation tents,(which takes from 7pm till 1130pm to clean and set up for him) start him on a morphine drip and he dies quietly and I am hoping comfortably around 2 am. His wife is completely distraught and we give her a sedative to calm her and let her sleep on one of the ER exam tables, as there isn’t any other appropriate place for her. After spending the majority of the night with Jeremy and his wife, I return to the ward at 3am to find two of the Haitian/American nurses assigned that night are nowhere to be found and have been missing for about an hour. So I take over their 50 or so patients, restart lost IVs, cath patients, give meds..etc. They reappear about 530am…they were tired (oh really?) so they went and slept!!! (one even changed her clothes!) I’m so frustrated (and angry and tired) by this point that even though I know they are leaving on the same plane that we are that day, and so it is a moot point, I tell them that they should be ashamed of abandoning their patients, they aren’t special, that all of us are tired, and that they placed a big burden on the rest of us, me specifically, and that I thought they were selfish and disrespectful….which essentially falls on deaf ears....but I feel better.
My day in Haiti ends on a really positive note in that I see Bazile, a Haitian doctor that I worked with in Burundi, who is in Haiti for a couple of weeks seeing and helping his family. He stops by a few hours before I am to leave Haiti and I meet his parents and one of his brothers. It is so good to see him, and the time spent is too short. He will be returning to Burundi and it is clear that he is conflicted….which I understand.
Leaving Haiti is, for me, conflicting, I feel as though there was so much more I could do (nothing big, I know better, just the ripple effect) and I am not ready to go and then on the other hand I am exhausted and very ready to leave in that sense.

Continued thoughts of the monumental problems that lie ahead for the Haitians and the patients I leave behind.
The homes of the patients who fill the wards are mostly gone. Their livelihoods may be gone for a long time as well. How do you discharge amputees, and people with cranial and spinal injuries, to the destruction of their old city? And if you don't discharge them, how do you maintain them in an overtaxed hospital. It has to be a dilemma facing the whole country.
How to impose continuity of care? The surgeon who labored to save a crushed limb is gone after a week. The nurse that started and maintained the IV, administered antibiotics, cleaned and dressed their wounds, emptied their bedpans and explained to the families the gravity of their condition, is also gone. Who follows? Will help continue to come to Haiti? Will it be enough? Only time will tell.
Eventually, beds now occupied by recovering, but homeless people will have to be cleared for more serious cases. Eventually, the challenge of kidney damage and the need for dialysis caused by the tissue death and circulatory problems of crush injuries will have to be addressed. There are mountains of problems with no clear solutions. What will be sustainable?
I can only imagine the work that lies ahead, but what I do know is the first person served by the service is the server and that I hope to return to Haiti in the future...and do the best I can.