Friday, February 12, 2010

Pastors Keep Community Spirit Going in Haiti

By Gene Gincherman, M.D.
Emergency physician and Go Team member

While on a trip outside Port-au-Prince (PaP)during a recent medical mission to Haiti, I noticed one essential quality to people's suffering there: namely, it's essential loneliness.

It was less prevalent in PaP, where people are closer together and seem to have more of a sense of community. In smaller villages, it seemed like more people fended for themselves. Some of them seemed to spend their whole days sitting in makeshift tents, not doing much.

It seems to me that if that idleness is allowed to continue, it will lead to despair, and further suffering. One experience on this trip gave me a glimmer of hope for the future. We happened to be visiting on Sunday, a day a lot of people in Haiti go to church. As a consequence, we got to meet with five different pastors.

Considering the lack of civil authority, they seemed to be the inspiration for their communities. They were interested in every aspect of daily lives, from fulfilling the spiritual needs to providing food, medial care and building latrines.

If Haiti is going to recover and overcome not just the outcome of the earthquake, but also years of mismanagement, suffering, and corruption, they need more people like the pastors we met.

Wednesday, February 10, 2010

"How Will Haiti Recover?"

Alicia Hernandez
RN and Go Team member

My last few days in Haiti were a new experience as I responded to a call for volunteers suddenly needed in the Petit Goave region of Haiti to replace the volunteers leaving the mobile clinic sites there on Friday.

A doctor from Chicago, Stacy, and I set out apart from the rest of International Medical Corps (IMC), and arrived to the mobile clinic where just two IMC nurses had been working with Haitian staff for a week.

It was a tent clinic in one of the tent city Internally Displaced People (IDP) camps that served the people living there mainly with primary care issues. The tent was supplied mostly only with oral medications and some wound care materials. The IMC nurses gave us a quick debriefing at around 11 a.m. and left us on our own by noon. Talk about getting your feet wet.

We jumped into the over 100 people waiting to be seen as the clinic had not opened that morning at the usual time. They were waiting for us to arrive with the restock of medications. We quickly began rolling through the patients.

I triaged with a quick initial assessment and vitals while Stacy and two other Haitian doctors saw and prescribed medications for each patient. Everyone got something if only multi-vitamins, although generally at least three different things from the Haitian doctors - mainly to treat coughs, UTIs, [other] infections, scabies and gastritis. Most were mild enough to send "home" with oral medications. We did receive one obviously sick man - most likely with TB - on our first day.

The dilemma was then where to send the patient as we did not have the capacity to care for him in the tent. We decided to send him with our personal driver to the nearest hospital. We found out later the hospital is currently only staffed with one doctor and one nurse. It has no functioning X-ray or laboratory. Stacy and myself had a debrief that night with the one other IMC staff staying in Petit Goave, Pascal the French logistician, about the current situation.

Pascal´s job had been to arrange everything for us from accommodations to transport to interpreters as well as everything for the mobile clinics - tents, staff, supplies and sites - and gathering all the info we needed to best serve in our clinics. He was our "go to" for more supplies to request from IMC or from other area NGOs and for knowledge on what services are available where.

Pascal Made A Big Job Easy

It was a big job - but he´s been doing this for over 15 years in so many disaster zones around the world he made it look almost easy. He said Haiti has been his hardest assignment yet. So Friday night the three of us figured out that there is an MSF - Medicins Sans Frontier, a.k.a. Doctors without Borders) hospital 45 minutes away. That was a better option for a referral than the nearby non-functioning hospital. We also set a plan to open a second new clinic on Saturday that Stacy and a few of the Haitian staff would go to while I would stay in the current clinic with the rest of our current Haitian staff.

Pascal said we would each have our driver although that didn´t quite get arranged in time and I manned the clinic with no phone, no driver, and no other IMC staff. It was me and five Haitian health care workers and over 100 patients again.

A Sick Girl - Typhoid

I was impressed at how well the Haitians were running things. It was all fine until we received a very sick girl, potentially with typhoid. I had no driver to take her to the hospital or way to contact anyone to ask for help. She had shortness of breath, cough with dark sputum, vomiting, diarrhea, and temperature of 104. The Haitian plan was to give her an antibiotic injection and some Tylenol and keep her on the examination table there to recheck her temperature after an hour or so.

If it started to decrease, they would send her home and tell her mother to just bring her back on the next clinic day, which was Monday, for another injection unless she improved. This girl really would have benefited from IV fluids, repeated IV antibiotics, and closer monitoring. I kept checking on her to make sure she was still breathing, as she looked grim, lying face-down on the cot, eyes slit, no movement. The scream she let out with the antibiotic injection was some extra reassurance she was still very much alive.

I continued to work, with glances at her every few minutes. A temperature check showed a slight decrease. After a couple of hours, with my last glance, she was gone. They had sent her home. There was no means to do anything more.

I still think about her days later and only hope she will be alright. Saturday Pascal had worked to secure us another driver and to find names of villages with potential need for more mobile clinics either due to vast quake damage and displaced persons or loss of the existing health care source from the quake.

Collapsed Buildings Common

Sunday was spent visiting these villages and assessing need. Collapsed buildings around Petit Goave are as common as in Port-au-Prince but with less open spaces, as in city parks. Actual tent cities were not as common. Tents simply lined the streets. Driving took some careful maneuvering and I can only imagine living in one of those tents where cars constantly pass only inches away.

One of the villages we visited was as poor and as devastated as anywhere we had seen. There were collapsed buildings on top of the poverty that already exists. It was also a place on the coast where the ocean floor had shifted and the water level rose and flooded everything near the coast. As we were driving through, Pascal said, "I´m sure there´s need here but where are the tents?"

It was interesting to learn there had to be obvious need resulting from the earthquake in order for us to spend the donor money there and help. They couldn't just simply need help. In another village, they had a fine standing facility that once served as a clinic. The complicated task then was to find out why it wasn't functioning now. Was it functioning prior to the quake? Was the facility damaged in some way? Were there staff losses? Were they just not showing up to work now because the government stopped paying salaries - or did they stop paying them because they stopped showing up? So many complexities involved in disaster relief, especially in a place like Haiti where the health care system was barely functioning in the first place.

Mission by Boat
There was another site Pascal had heard of that wasn´t reachable by car, only by boat from Petit Goave that was rumored to be affected by the quake and had received no services or even visits from outsiders since. So we put together a mobile boat clinic and sent them out Monday to do the assessment and [set up a] new clinic there at the same time. Apparently it was a success. Medical services were brought there and they were affected by the quake, losing their water source as well as their usual means of receiving medicine and food.

I had three and a half short days in Petit Goave and saw and learned so much. And I hopefully helped some as well. "Short" and "hopefully helped some" are two of my main thoughts as we head home now.

The biggest thought, however, is how will Haiti recover? How long will it take? What more can we do? What more can I do? How do I go home and back to life there? Haiti will stay with me now. I feel a responsibility to spread that to others. To get them more help, and to get back and do more. This leaving now is not the end of anything.

"...Why Did We All Do It?"

Gene Gincherman, M.D.
Emergency doctor and Go team member

As all of us start to decompress a bit in the Dominican Republic after our work in Haiti, more and more thoughts come to mind. It seems that the most fundamental question is: Why did we all do it?
It seems to me that the answer lies somewhre between doing it completely out of altruistic notion of trying to help people around you who are suffering horribly and going on an ego trip to prove something to oneself.
People who are in Haiti to save the world burn out too fast,and become a liabiity to themselves. People who go on an ego trip are unable to become good team players and destroy the sense of community that immediately develops in such austere and stressful environment.
I am proud to sat that the Johns Hopkins team has developed a sense of togetherness from the start, which played a tremendous role in our ability to take care of each other and our patients.

Tuesday, February 9, 2010

"Everyone is Sleeping Outside. Everyone"

Beth Sloand
RN and Go Team member

We drive 45 minutes each way, from the hospital in Port-au-Prince to Gressier. It has been an eye-opening experience, since prior to this I have only been between the hospital and hotel, a 5-minute drive.

* Everyone is sleeping outside. Everyone. Those who have their homes flattened, those whose homes have cracks, and all others. Everyone is afraid to sleep or work in any of the buildings until an official government engineer inspects a building and finds it safe to re-inhabit. This affects Port-Au-Prince and all the towns we passed on the way to Gressier. I suspect it affects the third of the country most heavily hit by the earthquake.

* Sleeping outside means that people are gathered together in tents to sleep. Tents are mostly sticks lashed together with sheets or towels or shirts stretched across. Sometimes, cardboard or tin or other materials are added to the mix. The tents are in large areas, such as parks or open spaces, all packed together. They are also pitched in small areas, such as the median strip of highways. Daily life goes on in front and within these tent areas -- people wash their clothes and their children, prepare their meals and eat. There is little privacy, a luxury here.

* There seem to be increasing numbers of sturdy tents from NGOs. “Shelterbox” provides beautiful tents for families, and I am seeing more and more of them in some parts of Port-au-Prince. That is a great thing, because many fear the rainy season and the difficulties it will cause people who are in flimsy dirt-floor tents.

* The condition of the roads, never very stellar in Haiti, is getting worse each day. As we drive to Gressier, our driver and translator exclaim periodically when we encounter a new split or depression in the road, probably caused by the frequent aftershocks. Says translator Denise, “the earthquake crashed the road more, and cut it worse.”

* An increasing problem: trash. Trash pick-up seems to be on hold as any large trucks and resources are dealing with the bigger issue of earthquake rubble. Meanwhile, people have nowhere to put the mounds of trash -- plastic bottles, cartons, wrappers, etc. Haitians tend to use and reuse whatever they can, so there is much less trash per person here than in the U.S., but what is here is simply adding up and combining with the dirty water in the streets. We saw one whole street with a continuous mound of trash 6 feet wide and 4 feet high that went on and on. People climbed over it to get to the other side of the street. Children played along the edge, a public health problem brewing. This also makes driving difficult, as you have to weave around the trash piles, as well as slow down for the new cracks in the road and avoid other rubble and wires. (There was one tangle of wires hanging across a street we routinely travel. One day last week, it had dipped so low that there was a spark when our bus went under it and didn’t quite clear. The next day, the wires were removed, thank goodness.)

* Clean-up crews of citizens have taken to the street. Men and women, young and old. We saw hundreds with blue T-shirts, armed with shovels and brooms and wearing masks to protect their lungs from the thick dust that is in the air. By the end of the day, there was a visible improvement in the look of some neighborhoods. These crews are dealing with the small jobs along the side of the road and the walkways. These folks are doing all the work by hand. I have heard that this effort is funded by the UN or an NGO, but am not sure exactly who or what. Certainly someone has provided the shirts. Bigger machinery must come to remove the huge concrete slabs and chunks of concrete bricks from destroyed buildings.

* Crushed buildings seem fair game for scavengers. In these circumstances, people are struggling to survive, and they are willing to dig through rubble to pick up pieces of wire, wood, and other items that they will reuse.

* Food distribution is a tricky business. We pass one area where the UN and U.S. soldiers stand a few feet apart in a long line to provide security as the distribution occurs. Some programs are giving the food to the women to bring home to families. Once, there was a brewing protest -- it seemed people didn’t like the method of distribution.

* Generally, a sort of daily life has somewhat returned. People are seen walking along the street, moving their wares to sell, bringing home food, children playing, etc. The streets we have seen are mostly quiet. There is no sense of violence or lack of safety that I have observed. One exception is when a foreigner sticks a camera out the window to snap a photo of people bathing or the tent camps, etc. Then there is usually an angry one or two people who yell in protest. Understandable.

The "End of the Road"

Tom Kirsch, M.D.
Emergency doctor and Go Team leade

I spent the last 3 days doing assessments. We were trying to identify areas with unmet needs to see if International Medical Corps can fill the gaps. We drove out of Port-au-Prince (PaP) to the west, down the long peninsula that reaches far into the Caribbean Sea to the towns of Leogane and Petit Goave. The road passes directly over the quake's epicenter and so the damage there was far greater than in PaP.

In some towns more than 90 percent of the buildings had collapsed. At points the road was ripped and roiled with larger fissures slashing along and across the road.
The area we went to was literally at the "end of the road."

The road started as a poorly maintained ribbon of asphalt that was more potholes than smooth and gradually faded away into a scrubby dirt track only suited for feet. Initially we drove through alternating areas of forest, banana or sugar cane farms, or crumbled towns. The dirt road started as a turn that ran south towards the mountains out of the town of Leogane through an essentially flattened town with few functioning buildings. Then it headed Southeast, paralleling a briskly flowing creek that was lined with shacks and concrete houses.

Only the shacks were really left because they were made of wood and palm fronds and metal sheets rather than the brittle and poorly reinforced concrete that crumbled into dust.

There were three scattered IDP (internally displaced people) camps along the roads. They were haphazard affairs with tents and shacks thrown together in closely-packed groups made from an assortment of tarps, scrap wood, and old, rusted corrugated metal sheets. The road ended at the last camp.

It was the worst of the lot. Only yesterday Save the Children had delivered tarps - which had been used to create shelters of a variety of interesting configurations. But there was nothing else there. They did have the creek which was used for drinking and washing and bathing and probably as a toilet.

Monday, February 8, 2010

"Children...Suffer In Silence

Beth Sloand
Pediatric Nurse Practitioner and Go Team member

The hospital is mostly outside in tents. Tents come from the Red Cross and Red Crescent of various countries. There are six pediatric tents. The infant tent has about 30 little cribs crowded inside - only a few inches separating them. IVs hang from tent strings. There are no chairs in the tents, so parents sit on their child’s bed. In the infant tent, parents slept under babies’ cribs at night on a piece of cardboard or sheet or whatever they had.

The American military, all in full uniform fatigues, and the Scientologists, with bright gold T-shirts, distribute food at times. A funny combo. There are two pediatric orthopedic tents, since orthopedic injuries predominate from the earthquake. Lots of broken femurs as well as other bones.

Children mostly suffer in silence. There is little crying in any of the pediatric tents. There is some pain medication given, but not regularly. Children tend to be stoic; they are not used to life being comfortable. Everyone is on antibiotics to treat or prevent infections.

Parents seem to have a pleading look in their eyes, or maybe it is my imagination. For all those hospitalized, a predictable hurdle is discharge. How do you discharge people who have no home?

Conditions in the tent camps scattered throughout the city are much worse, and it is difficult to know that recovering surgical patients will be living there.
I worked in the ER Monday, joining a team of about 16 nurses and physicians. It's a hopping place. We saw 470 patients. The range was wide -- a woman who had just been hit by a car, a man who was found unconscious on the street, a child with an infected orbital fracture, as well as those with back pain and headaches and fevers. We have a lab with basic capabilities; radiology that works for simple films, and a limited pharmacy. Supplies are available, but not always what you need or want. There are some Haitian nurses and physicians who are very helpful when they are around.
It is a loud place, with lots of yelling and people talking. The outside venue doesn’t lend itself to tranquility, and there are several patients being seen in the small area. We have three ER tents. In Tent 1, where I worked, I lined up kids and adults -- three or four -- on the edge of the bed, and then worked through them.
The questions are redundant: What brings you here? When did the pain start? Have you sought other care? And so on... My translator, Stevenson, was helpful and reliable. We often have to move patients off the bed for a more seriously wounded or ill person who arrives. Then we see them on a chair if available, or just standing. Not optimum, but it works.

Friday, February 5, 2010

A Place We Call 'The Forest'

Tom Kirsch, M.D.
Emergency physician and Go Team leader

There is a place in the hospital we call "The Forest."
It is the place where the lost souls end - a purgatory or limbo.
In reality it is just a courtyard with some semblance of shade from the scraggy trees and tarps strung among them. It is a square of dirt and scattered grass further by an ‘X’ of concrete walkways with a dead fountain at the crossing.

Originally it was a patient care area when the hospital was so inundated, filled completely with old beds and cots and blankets with tarps strung between trees; and then a further "forest" of intravenous poles and dripping fluids. We cleared out all the ill people a week ago and cleaned out the trash and feces.

Now it is just limbo - a miniature refugee camp. There are about 35 people still there, setting up camp on the old and mostly broken hospital beds. They have converted the IV poles into tent poles to hold up their tarps. They have brought in sheets and blankets and pillows and dishes and other small reminders of the homes they used to have. They do dishes, but don’t need to cook since food is available and there is clean water and port-a-potties.

This is the place where we let those with nowhere else to go to wander off to after we have completed their medical therapy. We aren’t supposed to transfer patients there because there is no one who is responsible to care for these people - we don’t have the staff.) But sometimes we mention to the most desperate people that they can just walk over there and grab an empty bed until the hospital administration decides they are no longer welcome.

Bernard is one of the lost souls. He is a thin, craggy, elderly gentleman with fizzy grey hair and a lost look in his eyes. He came in, or was brought in for unclear reasons, and was too confused or demented to give us a coherent story.

He had a paralyzed left wrist, most likely from a nerve-compression injury after the earthquake and was clearly dehydrated and maybe malnourished. He had no family or friends or the ability to tell us where to find anyone. We gave him fluids and food and a splint and he was done. But there was nothing else for him.

I walked him to the forest and sat him in a bed in the shade. I go by daily to see him. He sits there patiently, legs dangling from the rusted hospital bed. Always in the same spot with old foam boxes of food at his side, biting the corners off the little bags of water that the volunteers bring by, and then sucking out the contents. I never see him talk, or even walk, always just sitting there and watching. I wonder what he sees and wonder if he remembers.

There are so many lost souls like him that it is incomprehensible. They come and go like tides every day. Some stay in our Forest.

Thursday, February 4, 2010

All In a Day's Work

Tom Kirsch, M.D., Emergency physician and Go Team leader

For the most part I haul stuff, including patients. Yesterday I was an electrician and rewired a tent and put in more fans.

Saved a Newborn in Distress

Emmanuelle Clerisme-Beaty, M.D.
Go Team member

After almost a week I finally got to work in one of the medical wards, which is definitely more in line with my training. On my first night I covered the inpatient pediatric wards and the NICU. However after a rough start trying to take care of 60 patients with no nursing or ancillary staff, Mike and I ended our 16-hour shift by successfully resuscitating a newborn in respiratory distress.
To think that if this baby was born one day earlier, he would have died since until that night there had not been any in-house physicians until that night.

"...Bringing Light To The Darknesss"

Rocky Cagle, RN and Go Team member

We arrive to the university hospital around 7:15 a.m. We have a short debriefing and then off to our units. There is no way to know what we are in for each day. I meet with my interpreter and we chat about our previous night. I ask about his family, how his wife and kids are and he always says they are good. It's hard for me to comprehend they are "good" with their home destroyed and having to live in a small tent that is meant for two- but accommodating five. He says his kids love not going to school.

I think to myself that perhaps they have not yet realized that their schools are destroyed and the devastation of the earthquake has taken the lives of their classmates and teachers. After the brief conversation we are ready for our day, both of us knowing it's going to be long and hot.

We don't give the conditions a second thought as we are immediately focused on making a difference -- bringing light to the darkness that surrounds so many here.

Arriving on the unit I take inventory to see what supplies we have for the day. I have learned that many of our supplies are missing. Already patients are waiting for care. The long lines twist
down the street. American care is here and the Haitians have welcomed it with open arms. They have a robust confidence in the work we do -- often expecting a cure for the incurable.

As the chaos begins, there are doctors and nurse swarming the tents. Novice nurses work side-by-side the seasoned health care providers. The newest additions to our ER flounder briefly asking questions like, "Where is this antibiotic? Where is this narcotic? Will you start this IV? Can you figure out what is wrong with patient.? I am new here can you help with what I should do?"
The intensity drives all of us to push our limits and immediately adjust to the demands from all sides. After 10 hours of craziness in 100 degree heat, we finally come to a day's end and take time to reflect on the day.

Have made the right calls? Have we truly done out best to make a difference. The realization that our Hopkins group will have worked over 1,000 hours within 10 days, does not ease the demands I have for myself and the short-comings I have identified within myself. It's two weeks
out of my life -- a short time to do the good I set out to do.

Pierre, my translator has stood by my side all day. He's held my supplies at my side, tidied my workspace, and spoken every one of my words. He comes here every day to make a difference of his own. Knowing his family awaits him, he sets off back to his "home."

Despite leaving the ER for the evening, my mind is continuously rewinding through the day. How will I be better tomorrow? Am I good enough for these people who depend on us so much? I think of each face of each patient, each heart I have touched. The strain and stress can be overwhelming but I find a strength in those who depend on me. I will return tomorrow with a smile on my face, a soothing touch to my medicine, and shoulders to carry the burden of a broken country.

Wednesday, February 3, 2010

"I Don't Know How People Are Surviving Here..."

Alicia Hernandez
Emergency RN and Go Team member

Day 6 in Port-au-Prince: Half-way through our stint here. I can't believe it was only one week ago that we were first flying here. It feels like so many more. I hit a brick wall yesterday as we have all been working almost non-stop since arrival. Some since the minute we stepped off the bus from the Dominican Republic into the hospital. It's the long hard hours in the sweltering heat of the tent, the relentless flow of patients desperate for miracles we can't provide, the lack of sleep, and continuous failed efforts to stay hydrated and nourished. At least one volunteer has succumbed to the pressures everyday since we've been here, to the point of being unable to walk and needing IV hydration.

I came dangerously close to that point multiple times about every 2 hours yesterday, needing to find shade outside of the tents, and force down some oral re-hydration salts (ORS).
I had at least 3 liters of ORS plus more water and still couldn't last more than 2 hours in the tent without feeling like I was going to vomit and pass out. I realized I had to take more than the time it took to down a liter of ORS away from this work. Thankfully everyone else realized it yesterday as well and time off is now not only being more welcomed, but mandated. I quickly stepped up to the plate to take the first day off. I finally slept better, I think knowing I wouldn't face the pressures of not only caring for others this morning but caring for myself in this condition.
That alone was a huge weight lifted for the night. And I still awoke nauseous and still feel so now. But I'll get through. All of us are (with a few exceptions of early flights home for fear of serious illness). With being awake through the night not only because of the heat and stress and mosquitoes, but because of having multiple trips to the bathroom with vomiting and diarrhea. The bonus of doing medical relief is that we all have easy access to medicines and IV fluids with the know-how to provide it to each other. I started an IV on another nurse that went down in the middle of the day yesterday. I have been offered IV fluids and Zofran and cipro by many of my fellow volunteers.
Everyone cares and everyone understands. It's great camaraderie and great inspiration to see what we are all going through to try and make some difference here. And I like to believe it's in the small ways that we are. We are so limited in what we can do for the severely sick and without Social Work, it feels so wrong to discharge those without a home to go to but that is nearly everyone. I don't know how these people are surviving but they are. Not only that, but they smile and thank for the simplest things - some Tylenol, a little cleaning and fresh gauze on a horrendous wound that covers half their leg that they have to limp out on. And to where?
A two-tarp tent, waiting for the next food and water drop. We pass by their lives,
sheltered by the walls of the bus and the walls of hospital, see them cooking and bathing on the sidewalks, bustling to and fro. Life goes on in unexpected ways.

"We lose one staff a day..."

Tom Kirsch, M.D. (pictured right) with Rocky Cagle, RN

Tom Kirsch, M.D.

Johns Hopkins Emergency Physician and Go Team Leader

The day starts about 5:30 a.m. when the hotel turns back on the power. The fans come back on at least. People begin stirring, snores fade away,
backpacks rustle and feet pad around.
The lights usually burst on at six and then the activity intensifies except for a few trying to squeeze out a few more minutes of sleep. People dress, food and supplies are gathered.
The bus leaves at 7 a.m., driving less than a mile past normal buildings and lives and crumbled ones and tent camps. Vendors have already lined the streets
past the ramshackle tents in the city’s main plaza- food stalls, haircuts, a Gno Kozes (snow cones), but most interestingly the guy with the truck. It is well lit
by fluorescent lights and has a rack of blenders in the back making smoothies.
At the gate of the hospital there is already a half-block long line of patients waiting to get in.
By 7:15 a.m. we have completed out briefing and are pulling supplies.
The little triage tent is bursting with people.
A report is given by the night team- there are always leftovers – usually very sick. They bring the sick ones from the rest of the compound back to the ED if they go bad at night, and only the really sick come in after midnight.
Patients start pouring in.
Our tents are hot, probably 10-20 F hotter that the ambient 95 F air outside. They have few windows and the power only runs occasionally to run the
We loose at least one staff a day to heat exhaustion.
Yesterday it was the 6’2” nurse from Utah. Dizzy and pale, then down and vomiting.
We run IV fluids and bring them to a cooler area. We have started mandatory fluid requirements, and push people to take breaks and now will have a
mandatory ½ day off every 5 days minimum.
The army guys might hook us up to one of their generators so we can at least run the fans. I got pizzas and cold Cokes delivered from the outside yesterday. A strange comforting little piece of normality.
The buses head back between 5:30 and 6 and it is always a scramble to tuck things away, restock and sign out to the night people. We usually miss the
bus and bet the late one.Debriefing 6-6:30 or 6:45 (although I usually miss the first few minutes, preferring to sit with my sore feet dangling in the cold pool water and drinking a
beer). Dinner cafeteria style is at 8. Most people start fading out around 9. The few hardy (stupid? gregarious? Insomniacs?) sit on the patio late
talking and drinking $4 beers or soda until late surrounded by the reporters furiously working on stories and hogging all the wireless bandwidth).Finally sleep in the dark conference room with 40-50 people scattered around in various odd sleeping arrangements- bed mattresses, inflatable ones,
cots, even tents pitched indoors. The stirring, rustling backpack and padding feet gradually fade away and a low-grade background hum of stores rise up
and the day ends.

Tuesday, February 2, 2010

"They lost their house..."

Rocky Cagle, R.N.
Go Team member and ICU nurse
Today was a good day. We saw a good bit of patients today. As some of you may not know I am now in the ER because they needed more help there. The whole Johns Hopkins crew runs the ER. All 8 of us.
It is better than staffing the ICU because there is nothing I could do for those people. I am charge nurse of the ER so it is good to be running the show and having people look up to me. (Cagle in middle of photo left)
My Creole interpreter has a wife and three kids. They lost their house in the quake and his brother died. He had 5 U.S. dollars for the past two days to buy food for his family. He gets paid $20 a day but has not been paid them since last Friday, 9 days ago. They live in the tent village about 15 miles away. He has to take a cab to work every day which costs money. I got some MREs for him and his family today. His wife is washing my clothes for some money. I gave him $10 for him and his family. He said "How - I don't know how - I will ever repay you!"I plainly stated I couldn't do anything without him; he owes me nothing. I plan on giving him everything I have left if anything when I leave here. We were walking around today, and he decides to tell me a joke and his broken English, "as we walk here let me tell you joke, Jesus and Peter were hanging out. They were about to go on a walk but before Jesus told peter to make them a chicken. Just a chicken with nothing else to eat before their walk.Peter said OK and proceeded to make the chicken. When the chicken came out it only had one foot. Jesus said Peter what happened to the chicken's foot?
Peter said all chicken only have one foot. Jesus said Peter my Father made chickens and I know they have two feet. Peter said no they all have one foot.Jesus said well OK, and they went on the walk. Right outside is a chicken standing on one foot. Peter said look Jesus one foot, Jesus looked and scared the chicken and it ran off, with two feet.Peter said Jesus you always make miracles!It was funny and heartwarming.
Other than that we are dealing with patient that have dengue, HIV,tuberculosis, malaria, a lot of sores, gunshot wounds, etc.

"Saw some amazing cases..."

Gene Gincherman, M.D.
Go Team member and Johns Hopkins Suburban Hospital emergency doctor

Today I worked a day shift again, but took on a different role and became an ER flow manager, making sure that the patient flow got more efficient.

I was running around all day distributing patients between different docs, communicating with managers, teams from other NGOs, pharmacy, lab, etc. It was also important to make sure that none of the providers got dehydrated, and had their 15 minutes to swallow an MRE, and stay hydrated.

Tom Kirsh, M.D. (Go Team leader) took on the role of disposition manager, making sure that patients were moved out ofthe ER efficiently. I thinks all of the docs liked the system that Tom and I put in place today much better.
Unlike other days, not a single patient left without being seen. The volume was lower oday, only about 160 patients (it is Sunday in Haiti, and people are very religious). I suspect tomorrow I will have to manage the flow of 300-400, which may be more challenging.

I have a feeling I am now appointed to be the operational manager for the rest of the stay. Still saw some amazing cases: tetanus, possible cerbral malaria, saved a guy with a gunshot wound to the back,and another with a stab to the groin, that got his femoral artery.
I have become good friends with the medics from 82nd Airborne. They are great guys, and are very helpful.
One of them said something truly meaningful to me: "Don't let anyone ever tell you that you are nor making difference, no matter how frustrating it gets at times".
That meant a lot coming from a guy who's been to place that we as civilians can only fathom.

"He died two hours later."

Tom Kirsch, M.D.
Johns Hopkins emergency physician and Go Team leader

We work out of big, cream-colored tents, maybe 30 feet long and 15 feet wide. There are tents scattered all over the compound, from many different countries, but all with slight variations on the same design and a color range of white to tan. I guess they are the international standard disaster tent.

We have three tents for our ‘Triage Emergency Department’. Two tents stand out: the ‘Jiffy Pop’ (look that up those of you born into the microwave era), and the Blue Tent.

The Blue Tent is the infectious disease tent with six places for the emaciated people coughing blood that we think have advanced TB. There is an exceptionally brave and unassuming Infectious Disease fellow from California who works there, pretty much alone it seems. She is quiet and unassuming with dark hair and a serious look about her. And she risks her health and maybe even life every time she steps in there.

She works 10-11 hour shifts. At night the patients are alone to cough and gasp for breath, The patient I sent there yesterday was a 19-year old with what appeared to be advanced AIDS. He looked like one of those classic ‘refugees’ in a starvation area with racks of ribs cascading down his chest, sunken eyes and limp, lean arms and legs. By the time he got to us he was already breathing so hard that he had to sit upright and could only gasp out one or two word sentences. He was sweating and you could see every muscle in his torso working to drag in each breath.

We poured antibiotics, anti-malarials and fluids into him immediately, but because he reported coughing blood we moved him to our ‘isolation area’- the open space between our two tents under the shade of some trees. I moved his to the Blue Tent in the late afternoon knowing there was not much to do, but hoping the California doc could work some miracle.

The next morning I went by and was somewhat surprised to see him from under the tent flap still sitting in his bed. After donning an N-95 mask I went into to the dark cramped tent among the shrunken, slightly stirring bodies to get a better look. He sat exhausted and glassy-eyed, sweat streaming off of him and making small grunts with each breath. It took him all his remaining strength to keep himself breathing thru the night and now he had no reserves left. I just tuned and left.

He died two hours later.

"Heartbreaking to see..."

Today was another day in Haiti - hot. I work in the ER now because there are great needs there. The Johns Hopkins crew is pretty much running the ER now with good outcomes.

We saw 470 patients today (triage at University Hospital in picture at left); others walked away. There is a lot of continuity of care and we work together well. We see cases from tuburculosis, malaria, typhoid, tetanus gun shot wounds, motor vehicle accidents, CHF, etc. We are good at diagnosing these cases but there is a problem with medications; they are hard to come by.

We could save most of these patients with good facicilities and meds. It's heartbreaking to see people that we know are going to die without treatment that we can't perform. Ten more days to make a difference in these peoples lives. If I only make one difference in one life, it will be worth this effort. - Rocky Cagle, Hopkins ICU RN.

Sunday, January 31, 2010

There are Many Children Who Need Care - But Few to Deliver It

By Beth Sloand
Assistant Professor in Hopkins School of Nursing and Hopkins Go Team Member

I spent the day in the pediatric wards, which means four Red Cross tents filled with children and parents-- all sick, many recently post op, most with no homes to return to.

It was a challenging day. There many children who needed care- but few to deliver it. The supplies were difficult to come by; things were very confusing- with Swiss physicians, Haitian doctors and nurses, and us with our translators.

I had one translator, Daniel, who was a sort of EMT--he set up the IV for a child whose IV had blown. There was no nurse or doctor in the pediatric orthopedic ward,-- none-- from mid- morning and for hours later. I tried unsuccessfully to find someone who could care for them. After several mothers and fathers asked me for help, it became clear that there was no one else to help, and so I drew on my hospital nursing experience from years ago and managed the IVs, pain meds, dressings, antibiotics, etc. A bit overwhelming but there was not much time to think about it.

There is so much new to me here. Though I have been in Haiti multiple times for many years, this post-earthquake situation is a war zone. There are so many people here who have come to help, but that is both a blessing and a challenge. I am fascinated by the role of NGOs in this disaster situation. Groups we have worked with here: the Haitian Red Cross, the Swiss Red Cross, the World Food Program, Unicef, the U.S. Army 82nd Airborne group (complete with big guns), Wings of Help (Germany), Spanish helpers whose organization I don't remember, the Scientologists, etc, etc. The challenge is huge, with coordination, communication with various languages, cultural differences, etc. Then there are the Haitians, who are in shock and grief mode. The Haitian pediatricians that I worked with seemed numb, sad, barely there. All understandable. But that is difficult because we really need their expertise.

One sad thing- there was a nursing school on the grounds of the University Hospital here. It collapsed. The bodies of many nursing students are still there-- somewhere between 70 and 140-- I've heard varying estimates. No matter- it is terribly sad because this building is on the hospital campus and I walked past it several times today. The bodies are entombed there. So that represents another huge issue- the Haitian health system has lost many, many nurses, physicians, and others that are so important in the already stressed system. They will have to work without these many professionals as they rebuild the country and health system. As a nurse educator - I am still struck every time I walk past that building. So very sad. Can't get used to it.

Haitians Seeking Primary Care

By Thomas D. Kirsch, MD, MPH, FACEP
Associate Professor and Hopkins Go Team Member
Dept. of Emergency Medicine - The Johns Hopkins School of Medicine
Dept of International Health - The Johns Hopkins Bloomberg School of Public Health

Work here is hard- 12 hour days, essentially on your feet constantly in boiling hot tents with limited electricity.

We have truly transited to the primary care phase, although occasional people come in with untreated wounds and fractures from almost 3 weeks ago. There is so little that we can do it seems, with the limited resources we have, and even less to do for an essentially non-existent Haitian health care system. We can treat acute infections, but pretty much anything else is almost impossible.

People are pouring into us because they think that we can give them the care they can never get in Haiti - horrible and massive cancers, HIV and AIDS, chronic abdominal problems, diabetes, whatever. But all we can do is bandage, fix the acute problem and give a few pills to go and hope that maybe at some point they may get the long term health care they deserve. Still, we see 250-350 people a day and give the absolute best care we can considering the resources.

The team has been amazing and has taken over the management of the emergency department. Everyone is pulling their weight (and then some) and using their intelligence, wit and grace to make this place better everyday (despite the ongoing chaos).

Saturday, January 30, 2010

First Day Realities in Haiti

By Alicia Hernandez
Johns Hopkins Go Team disaster medicine team member

Expectations have so drastically changed every hour along the way here that I can't even compare the reality to expectations.

We had heard earthquake-related medical needs are over and yet one of the patients we received today was a little girl who had bricks fall on her legs during the earthquake and only came in today for it. She had bilateral femur fractures. I'm not sure how things will turn out for her.

The day was filled with the questions 'What can we really do for this patient?' and 'How many resources should we really use?' Considering every bag of saline and every glucose meter strip when we were down to 4 of each for the day by noon.

So much of this care involves deciding who to let die. The hard part means watching them die and watching their loved ones deal with their deaths. In these places, you'll see a brother, who's 40-something previously healthy sister just died, say "Ok" with a nonchalant shrug when informed that she's gone. Like, "just thought I'd ask." And it seems like they are so hardened to this because they are dealing with it regularly, and dealing with so much worse.

But with this particular individual, we had the privileige of treating his father in the same day and keeping his company throughout the majority of the day. Even after his sister died, and worrying about his father's treatment in the same place, he was cheerful and thankful.

There was a moment, however, where the hardening softened, and he collapsed down onto the stretcher next to his father that was finally briefly freed of another patient, and sobbed, when he thought no one was looking, for a brief moment.

Each death was different, each patient was different; from gun shot wounds from a riot setting to chronic illnesses sent from other hospitals also drowning in the situation, to Jane Does with nothing left we could do - no family, no identity, and who still hung on for hours. There is so much need, and so many people who want to provide, and so many obstacles.

And this is just our day One. We will make a difference. I am determined. I don't know how. I know even less so how than I thought I did three days ago. But with the good will and determination I sensed today, it will happen, no matter how slowly.

Haiti - The First Day

By Rocky Cagle
Johns Hopkins Go Team disaster medicine member

On the first day here at University Hospital in Haiti I was assigned to the ICU. The role of the ICU here is to received patients that are complex from the ER and post op from the OR.

As I walked onto the unit at 7 a.m., I was looking for nurses to receive a report from them that took care of these extremely sick dying patients at night, but there were none. I began rounding with an American RN to "train" me for this ward to take charge of it for the next 2 weeks while I'm here. As I walked from patient to patient reading their 1-2 page chart, I realized I was in for a rough 2 weeks. The unit had no electricity or lighting. I was soon starting IVs with my headlamp and taping the IV with out dressings because of lack of supplies.

Many people needed to be ventilated but no vents. There was no privacy for patients if you can only imagine one room with 10 pateints and one RN for those patients.

Working with my Creole translator I didn't see a doctor until 1130 a.m. Working off what I have taught to the best of my ability, I worked for the rest of the day with a Haitian doctor, an American RN and an Haitian RN taking care of 40-50 patients.

Patients here are in great need of our help and are very thankful we are here.

Tuesday, January 26, 2010

Johns Hopkins Go Team prepares for recovery care efforts

On Jan. 13, 2010, Haiti experienced a 7.0 magnitude earthquake. The earthquake caused extreme devastation, hampering communication and relief efforts. Johns Hopkins medical response group - Go Team - made it their priority mission to help relieve Haiti.