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This blog exists only as an archive. It is a journal that serves as a window into my life as a Marine combat veteran serving in Iraq and Afghanistan; it was written with no filter, no politics and no agenda. Please feel free to follow my journey from beginning to end. Welcome to my life.

Tuesday, January 19, 2010

Haiti through the eyes of a SF combat medic, Mark Hayward

A day of extraordinary circumstances, and opportunities to be of service.

We rolled out this morning in our first “dedicated” vehicle: a
tap-tap that we had hired for the day, to serve as our transportation
and evacuation asset. We had been directed to the chapter house of
the Sisters of the Sacred Heart of Jesus (and I hope I am getting the
name right), better known as the Little Sisters of Calcutta (Mother
Theresa’s organization). Our medical supplies were critically low,
particularly in the antibiotics that are essential to treating these
nasty festering wounds.
For some reason, although the Jesuits have
received enough donated bottles of almost-expired pediatric acyclovir
suspension to fill a small room, we couldn’t find any more Augmentin,
Keflex, or Septra anywhere. So, as soon as we arrived at the Sisters’
and unloaded what we did have, Brother Boynton set out in the tap-tap
to try to secure some additional antibiotics from the main hospital
while the rest of us set to work treating the long line of injured.

This was very different from what we had seen yesterday for a number
of reasons. First and most importantly, the Little Sisters were
already doing an excellent job of basic wound care, and were providing
that service to anyone who came to their house. By the time we
arrived, the vast majority of the “simple” cases, those which could be
properly addressed with cleaning, bandaging, and dressing, had already
been seen and treated. Of the forty or so who remained, there were a
handful of simple wounds, with everything else ranging from complex to
incomprehensible. “Simple” things like unset tib/fib fractures and
infected orthopedic injuries were challenging and we ran through our
antibiotics in an hour. We then faced some ethical dilemmas that were
just unreal. What can we do for the grandmother with the unstable
pelvic fracture complicating her adequately healing lower extremity
wounds? And what SHOULD we do in light of the fact that our
resources are limited and we have a seemingly infinite supply of
patience. I examined an infant, perhaps 9 months old, who was way too
quiet in her mother’s arms, and did not protest at all as I carefully
examined the dent on her left forehead where a concrete block had
fallen on her six days ago. The thick yellow pus draining from her
left ear made it pretty clear that there was nothing I could do for
her no matter WHAT we had available. So I did my best to make her mom
comfortable in the shade and went on to other patients. I triaged the
patients into three groups: the handful of “simple” wounds or
fractures; the most numerous “complex” patients with fractures and
wounds; and the four patients who were beyond our ability to treat
effectively: the grandmother with the pelvic fracture, the infant with
the head injury; the 14-year-old girl with the fractured femur; and a
woman in her early twenties whose bandaged left hand and forearm had
the same greenish-brown stains and sharp rotting smell as the
gangrenous wound from yesterday. Since those patients needed
hospital assets, and I didn’t have any, I set them aside, and we got
to work on the other ones.

I want to say something about this team. Our two firefighters are
also trained to do EMT medical work -- package the patient
appropriately and transport to definitive medical care. Our former
Marines have had combat lifesaver training -- shoot back, put on a
tourniquet or a bandage, try not to get shot in the process, take the
casualty with you so that next echelon medical care can take care of
him. Our novice Shaolin monk has whatever combat medical training
padawan Jesuits receive, but I have to presume that “transfer to
higher medical authority” figures prominently in the lesson plan.
Even in my current medical paradigm there is always a “next echelon”
-- if I can’t take care of patients myself, I send them to a
specialist or have them admitted to a hospital. Our two doctors ARE
the next echelon but even there they can send patients to specialists
or subspecialists or add tests and imaging and whatever. The
difference here is, there IS no next echelon (or wasn’t; I’ll get to
that). So it is a huge paradigm shift to go from being “a cog in the
machine” to being “the only game in town.” I would certainly like to
be able to hide behind the docs, to say “hey, tell me what to do, I’ll
just assist you.” It would frankly be reasonable to expect that the
firefighters and Marines would do likewise. But when I turned around
after finishing triage, nobody was waiting for orders. EVERYBODY was
providing final-echelon patient care, Haitian earthquake style.
Whatever we did for these patients was most likely going to be IT.
And our guys were getting IT done, calmly, without panic or fumbling,
working in pairs or on their own to provide the kind of medical care
we had provided yesterday. *I* didn’t know what to do. Usually the
triage provider floats around and checks things to make sure the
junior medical providers are doing their job. But wherever I looked,
I saw that my non-medical comrades were doing just as good a job as I
could, providing simple and (I believe) effective medical care with
the most basic supplies imaginable. It was humbling and inspiring.
So *I* just started treating patients as well; lowest complexity
(wound care) first, in order to make space for more patients in case
we got another surge and had to reorder our treatment priorities.
And we were on our way to clearing the board.

That’s when Brother Jim got back.

He called us in for a quick huddle. He had been to the relief
agencies and the main hospital. Not only did they not have the
medicines we needed, they didn’t even have the doctors THEY needed. I
don’t know whether anybody suggested it or whether we just recognized
our next requirement, like a flock of birds in flight changing course
like one organism. We loaded our four “next echelon” patients onto
the team exfil tap-tap, saddled up with Brother Jim, the two docs, and
myself, and left two firefighters and two Marines to provide medical
care for a dozen badly injured patients, without a second thought.
(Uh. Maybe I should censor myself here. In medical legal terms
that’s spelled “patient abandonment.”) But it was the right thing to
do and I would do it again in a heartbeat. Our guys were providing
care for those particular patients that was just as good as anything
the docs could have done. In fact, the splints they were making were
BETTER than what I could have done -- our firefighters are superb at
improvising splints. And so our Marines and Shaolin monk worked with
them to take care of the last patients while we went to the
“next-echelon” hospital.

The hospital was and is guarded by troops from the 82nd Airborne and
it was surreal to once again be the bearded guy in civilian clothes
being ushered through the perimeter in a nondescript local vehicle.
As soon as we got inside, local volunteers swept up our patients and
assisted/carried them in through the front (receiving) door of the
hospital. We went in the back door (staff entrance) and straight to
the “ER”, which is sort of like the triage and acute/stabilizing care
section of the hospital.

Our OB-trained doc immediately went off to surgery. I wasn’t with
him and I can’t make a direct report on what he did. I do know that
at the end of the day, during our daily CISD/prayer meeting, the team
members who saw him at work were in awe of him. He is a quiet little
guy with a passion for reducing worldwide infant mortality through
homemade oral rehydration salts. From what I understand now, he is
also a gifted and fearless emergency surgeon. I’ll try to find and
forward notes made by team members who watched him work. For now I’ll
just describe my experiences.

Our ER-trained doc and I were effectively placed in charge of the
emergency department as soon as we arrived. The staff of volunteers,
both Haitian and US, were amazing. They also had very little formal
emergency medical experience. The two physicians who were in charge
when we arrived were a cardiologist and a physical medicine/rehab
specialist. I have the highest regard for these two physicians and
their sheer bravery in coming into a setting like this, seeing that
someone needed to be in charge, and stepping up to the plate. They
were also clearly exhausted and encouraged our doc and myself to do as
much patient care and staff direction as we felt comfortable doing.
And so, we did.

The patients ranged from traumatically injured to previously very
sick and then left unattended for almost a week. Many were
pre-surgical, being stabilized at a very basic level and prepped for
mostly orthopedic surgery at the first possible opportunity. For the
most part, everything we saw was very comparable to the patients we
had been identifying in our field operations as requiring next-echelon
attention. So, now we were the next echelon. The problem was, there
weren’t a whole lot more supplies than what we had ourselves. For
instance, the hospital also was out of Keflex, Septra, and Augmentin.
But, one thing they did have was plaster-of-Paris casting rolls. And
they had a LOT of patients with fractures.

I haven’t worked with plaster casts since the first phase of Special
Forces medical training in 1995. I hate the stuff. But it was all we
had. I asked for a bucket of water, which a volunteer from New York
(an American Airlines flight attendant) brought to me, and opened up
the plaster. At which point a whole lot of people gravitated down to
my end of the ER to watch. Apparently I wasn’t the only provider who
had gone a long time without making plaster casts. I’d like to say
that it all came back, but it didn’t. I started on a long-leg cast
using six inch plaster rolls (which, again, were all we had). It
sucked. When we got done (after half an hour of work), I checked the
cast. It didn’t immobilize the fracture site and the joint above and
below the fracture. I cut it off the patient and went to look for
more casting material. And lo and behold, where the plaster had been,
were three rolls of four-inch Ortho-glass! I could have wept for
joy. The stuff went on with the smoothness and simplicity of an Ace
bandage. I felt like crying from sheer relief after the frustration.
The patient was also delighted. For the first time in six days, she
could move her leg without excruciating pain. The cardiologist took
over discharging and providing post-op instructions to the patient,
and I went on to the next one.

Nothing was as bad (for me) as struggling with the plaster, but the
patients were non-stop. I did a digital block on a five-year-old girl
so that I could debride a wound that had split the tip of her left
great toe almost to the bone, and then festered for a week with no
medical care except for bandaging. She was entranced by the “Flight
of the Hamsters” game on my iPhone and played non-stop while I worked.
Our firefighters and Marines arrived and it was like a real
Christmas, one in which you get reunited with people you love. An
emaciated woman was brought in by wheelbarrow, supposedly for foot
injuries. Something didn’t smell right and I borrowed our team
leader’s combat fighting knife so I could cut off her clothes and
check for further injuries. As soon as I could see her right hip, I
knew that she was going to die within a very short time. A decubitus
ulcer had exposed the entire greater trochanter of her right femur.
“Cherie, avez-vous la SIDA?” (“Dear one, do you have AIDS?”) “Oui.”
I let the rest of the team know and we finished removing her
urine-soaked clothing, exposing more necrotic decubiti. I could have
put my thumb and forefinger around her upper arm. We made her
comfortable; as far as I know, there was no area for expectant
patients. In normal times in Haiti she would have died where she
lived, most likely under a sheet of cardboard in an alley. Only in
the aftermath of an unimaginable natural disaster would she even have
been accepted into a hospital. I continued on with other patients. I
bivalved a plaster cast with trauma shears and my folding knife,
exposing a gangrenous wound over a shattered compound fracture of the
tibia and fibula. We brought more and more of our own supplies in to
replace or supplement ones that the hospital needed. I couldn’t start
an IV on an eight-year-old boy who had lost his right eye and was
going to the OR for the amputation of his rotting right leg. I
restarted an IV on a girl with possible internal injuries who had been
brought in barely responsive and who was now able to carry on a
semi-coherent conversation and laughed when I clowned around and
danced for her while I worked. And so forth, and so on, et cetera.
Even our own patients (the girl with the fractured femur, the
grandmother with the fractured pelvis, and the young woman with the
gangrenous hand) came in. They looked relieved just to be in a
hospital, no matter what the conditions. I did not see the mother and
her unresponsive baby. Eventually, we ran out of daylight, and left
to ride our chartered tap-tap back to the novitiate house.

Dinner this evening was rice and beans with sauce, and boiled
potatoes. After dinner, Brother Jim led us in our evening prayer and
facilitated our daily combat incident stress debriefing. The
firefighters are scheduled to leave tomorrow. That bothers me more
than every gaping wound and dying patient I saw all day. How the hell
am I going to do this without my teammates? It started to rain just
as we broke up the CISD. I prayed (joined, I think, by everyone else
on the team), harder than I ever have prayed for any weather change,
that the rain would STOP so that the people of Port-au-Prince wouldn’t
get wet. The rain stopped. Sometimes it happens that way; sometimes
it doesn’t.

--Mark

4 comments:

  1. You are doing great work in Haiti, keep it up! Thanks for reporting back and sharing your experiences.

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  2. Great work ... and prayer :D Mother Teresa's nuns (note spelling) are the Missionaries of Charity. Breaking news is that there was just another big 6.1 aftershock this a.m. Let us know how this has affected your work.

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  3. I am in awe of the amazing work you all are doing and wish I had the ability to be there now. I am keeping your team in my prayers!

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  4. Amazing read. I'm a general doc looking at helping in haiti soon and was wondering what on earth I'd actually do when i got there. I suppose you do what you can. And you do it together! Thanks for the medical report. And all the best in the field to you and your team.

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