I have seen more truly grotesque and horrible injuries in the last 24 hours than I have seen previously in my entire medical career.
Using information from the Jesuit Refugee Service, our team loaded the available medical supplies onto two small pickup trucks and rolled from the Novitiate to the southern part of the city. We had been informed that there was a refugee/displaced person camp with about 900 people including a number of injured. We drove through the city, again seeing a generally orderly populace, with PNH managing the lines and traffic jams at locations like a tanker truck distributing free fresh water from the Dominican Republic, and gas stations with long lines despite very high prices. We got to the displacement area (N18d31.529’ by W72d19.167’ if anyone wants to find it on Google Earth), which was simply a small park in a hillside neighborhood where most of the houses had collapsed or were badly damaged by the quake. It was very crowded but again orderly. No one mobbed us, no one yelled or fought. The locals were happy to see us, took us to a shaded area that had been cleared of tents (there are an incredible number of WalMart red Ozark Trail tents being used by displaced families; a brilliant use of scarce relief funds and my hat is off to whoever provided them). The locals brought a dozen chairs, there were neighborhood people who had volunteered to act as medical translators, we broke out our equipment and organized a little supply area/treatment area/micropharmacy, and started seeing patients.
The first patient I saw was a young man of 18 years. I asked him his name, joked with him as I unwrapped the slightly stained gauze bandage covering his right hand. He held his hand cocked oddly at the wrist and the dressing was bulky and strangely lumpy. I kept soaking and peeling layers and I couldn’t understand why I wasn’t getting to his hand. The bandages were gray-green and had an odd smell. Since I’m not a complete idiot, I eventually realized that he was missing his two middle fingers. However, when I peeled off the last layer of bandages, I was appalled to see that he had sustained a traumatic amputation which had progressed to gangrene in the six DAYS that he had waited for basic medical care. His extensor tendons were like white cords in a slurry of decaying flesh. Mercifully, he was not in much pain. I cleaned him up as best I could, dressed his wounds, started him on antibiotics that MIGHT arrest the infection in time for him to lose only his hand and wrist but save his forearm. I asked him his name three times because I didn’t want to forget it, so that I could pray for him and commend him to you for your prayers. I DID find out that he was left-handed (thank God!), and I sat him down in a shady area while Dave and Jim got on the phone and starting using all their connections to find a hospital where he could be taken so that someone could cut off his right hand. I was a little rattled, but I like to think I maintained a good professional demeanor. And I got back in line and started unwrapping the next patient.
I will not describe in much detail the rest of the day. I can only assume that it was like Christmas in hell. The number of rotting, crushed, deformed limbs I unwrapped was ridiculous. If any statisticians are reading this, our team has estimated that we saw roughly 200 or more patients today. About 100 had various fractures, about 100 had wounds ranging from merely severe and painful, to grossly infected and frankly gangrenous. We set aside five patients for special treatment, meaning that their injuries were so severe that they required either amputation (hands) or orthopedic surgery (fractured femur, fractured pelvis).
Our technique for wound care was simple. First, soak off the bandages (if there were any). Second, wash/debride the wound with chlorhexidine gluconate (purple and viscous, like warm grape jelly). Third, remove any foreign debris. As an aside, foreign debris in this case means chunks of cement. Everything in Haiti is built of cement and I don’t recall seeing more than a handful of wounds that lacked the obligatory cement fragments, from the size of large sand grains to small peas. Fourth, cover the wound liberally with silver sulfadiazene cream (“the paste”). Fifth, dress the wound with sterile gauze and clean gauze wraps (Again, God bless Saint Mary’s hospital for providing these supplies!). Sixth, educate the patient on wound care and oral antibiotic therapy. Repeat. and repeat. and repeat.
For variety, mix this with crushed and broken limbs. Lots of lower leg/ankle and forearm fractures. Ortho-glass? Too bad; we didn’t have any. Instead, we used sticks and cardboard boxes. Jeff and Craig, our firefighters, were our designated splint team. A doctor or PA would identify a fracture (clinically -- no Xrays), describe its presumed location, and the fire guys would build a splint. Every one was a snowflake -- no two alike and each one a work of art. We’d send the patient off to find a stick so they could be non-weight-bearing for six weeks -- without crutches. Or sling, or swath, or just build something that looked like it might work, and pray. (Did that a lot, actually.)
Tired of that? Figure out the best antibiotic for the patient based on the wound. How rotten is it? Oral antibiotics only, please. If it’s just sick and oozing pale green mucus, they get Augmentin. If it’s only festering, just silvadene cream, because we’re running out of antibiotics already. If it’s in between, guess and pray. Five days’ therapy to conserve supplies. The kid’s only four; we need Augmentin suspension because those leg wounds are extensive and look really nasty. The kid’s memorable because he’s the only one who screams. He does scream a lot. But then again, we don’t have any anesthetics. Or narcotics. Or IVs. Or, for that matter, very much of anything. The baby over there needs ophthalmic antibiotic ointment. Do we have that? Dammit, dammit, damn-- hey, wait! We have TWO tubes in my tactical eye kit in the “advanced medical bag” (otherwise known as my American Tourister carry-on)! Asking patients “does this hurt? Are you OK?” Yes, they agree, it hurts. Thank you for coming to help me. Just tell me before you do ‘that’ again (debride, pack, pull traction, whatever). Thank you for coming to help me.
Our team is unbelievable. Combat Marines are scrubbing away at wounds, joking with patients through volunteer interpreters. We got a new team member this morning, Edmund, a novice Jesuit monk from Vancouver. Since he studied Shaolin karate as a kid, he is, of course, our Shaolin monk. I tell him to stick with me and bring me things. Within 30 minutes he is debriding and dressing wounds with minimal supervision. He also speaks French, so he interprets when we have more patients than volunteer interpreters. None of the patients complain. None of them ask for a meal tray and a Sierra Mist. None of them tell me they are allergic to every medication except Dilaudid. They are humble and quiet and stoic and grateful and very badly injured. I will never say anything disparaging about “Haitians” as a group again.
Brother Jim, on non-Shaolin monk, mixes patient care with provider care. He makes us drink water, eat a granola bar. We are running out of everything. Well, more accurately, that’s pretty much where we started. Fortunately, we are also (incredibly) running out of patients. Or at least running low on patients. We have a few stragglers who are in bad shape (midshaft displaced angulated humeral fracture? Yeah, that one merits another call to a hospital). We force Jim to take a break and hydrate. We turn our backs and he is up again looking after patients. Finally, with a sense of shame, we call a halt to our operations: we have to shut things down so we can get back to the novitiate house.
We’ve planned our return travel, but we did not realize we would be evac’ing patients. We catch a lucky break when one of the critically injured patients is able to have his wife borrow his cousin’s car. She drives him and two others to the hospital, including the young man with the gangrenous right hand. We are down to two patients who can’t travel by car: the guy with the femur fracture and the kid with the fractured pelvis. They are both litter-only, or, since we don’t have litters, door- and tabletop-only. Did I mention we are in a hilltop neighborhood? The kid with the pelvis fracture is about 13 and obviously in considerable pain. We give him some ibuprofen. Too bad it’s not Vicodin. Dave and Will and Jim are dialing for dollars again on their cellphones, trying to find hospitals that will take these patients, trying to find vehicles that can carry a kid lying on a closet door with his lower extremities “secured” with sheets. I talk to the kid and crack jokes in really bad French. He laughs, then bites his lip because laughing REALLY hurts. We find a ride for the guy with the femur fracture. I’m hanging out with the kid. Divine inspiration strikes and I pull out my iPhone. Within minutes he has not only figured out how to play the “Flight of the Hamsters” game app, but he has beaten all my high scores. I cheer him on as he sends hamsters into the stratosphere. A little cloud of other boys gathers at the head of his door to watch him play. Frankly, they look a little envious. When we arrange ourselves around his door like pallbearers to lift him up and carry him downhill, he continues playing. He is still playing when we load him into some guy’s car to get him to the hospital. I apologize for stealing his iPhone before he leaves. He laughs and says “thank you.” Away he goes.
We arrange our own transportation, now in darkness. We are taking some calculated risks in our security planning, but there’s no sense of hostility from the locals. Frankly they seem a little puzzled. It’s as though we are some quirk of nature, as random as the earthquake: we show up, we provide medical care, we go away. And in fact we do go away, winding our way through the rubble-strewn streets, back to the novitiate house and a home-cooked meal. The displaced persons are divvying up a shipment of humanitarian rations (“donated by the US”) as we depart their encampment. There’s minimal pushing or arguing. People clear obstacles from our path and say “merci” as we leave.
I think about it after we get back to the novitiate. I think about it after a meal of spaghetti with hot dog slices and ketchup, and a sponge bath in a pan of well water. I think about it after a CISD led by Brother Jim and an AAR led by Brother Jake. It’s all just weird. I consider being angry at a long list of people. I AM angry at the wastefulness of it all. Losing your hand or foot in Haiti is an economic death sentence. If we’d been here four days ago with SOAP AND WATER we could have saved limbs. If we had casting material and crutches we could have prevented what are guaranteed to be a number of deformities. And if we hadn’t showed up at all, things would have been worse. I give up trying to make sense of it and I sit down to write the name of the young man with the gangrenous hand so that I can commend him to you for your prayers and consideration.
At this point, with a profound sadness, I realize that despite all my efforts, I have forgotten his name.
Please keep him in your prayers nonetheless.