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February 4:  Coming Home, one of the hardest decisions of my life

Two days ago I walked into the courtyard of CDTI (the hospital where we had been working for the past week) and for the first time since my arrival it appeared empty. It wasn't, of course. There were still ten large tents with eight patients in each plus many more tents where other people were waiting to go to other locations or family members of patients were staying. But the courtyard was, for the first time, not congested with patients with crushed limbs, infected wounds, and burns waiting to go to surgery.  The hallway leading to X-ray, usually jammed with injured people, was empty. I got our driver and Brother Jim (our wonderful Jesuit brother) to go with me to make another sweep of any refugee camps that we came across to see if there were yet more injured waiting to be connected to definitive care.  As expected, we encountered hundreds of people requesting minor care – all the same problems that clog ERs back home – but there were few if any remaining untreated victims of the earthquake.  Moreover, larger organizations such as the Red Cross, Doctors Without Borders, and the UN were making their presence known.  And in some cases, they made it clear that they did not need or want assistance from small NGO groups like ours.  So, despite my original willingness to stay much longer, it appeared that I was no longer needed. I thought of all the work waiting for me at home and then I paused, taking a deep breath and hoping for some divine guidance. And then, reluctantly, I decided to leave Haiti.  

Even as I made the decision, I saw the faces of some of my new friends who planned to stay longer, and felt that I was betraying them.  But once the decision was made, I committed to it.  Loading my pack to go home, I tried to leave anything and everything that I could.  Everyone promised to stay in touch, but I knew it was possible that I would never see some of them again.  I trudged to the area of people waiting for humanitarian flights out on military planes.  The ICE inspector saw my military ID, my Marines T-shirt and Navy cap, but was confused by my five-day beard and the filthy clothing.  The X-ray machine picked up the K-bar knife that I carry everywhere buried deep in my rucksack.  The inspector told me he would have to take it from me.  There was no way I was giving up a knife I had carried through two combat deployments.  I called my friend to return to the airport to pick up my knife.  The ICE inspector interrupted with a whisper, "Forget it, just bury it in your pack." Finally making it to the flight line I realized that the body scanner had missed the equally large bandage/tissue knife in my pocket.  Oh well.

For the next 14 hours we waited on the flight line as plane after plane came and went without picking up passengers.  Each time the refugees would get more anxious and agitated. Finally, near midnight, a C-17 agreed to take on passengers for the return trip to Orlando.  Over 300 refugees and returning aid workers scrambled to get in line. When we got inside the plane it was empty.  We were told to sit on the floor with one large group strap across our legs to serve as a seat belt.  Then another plane arrived willing to take passengers. The crew asked for volunteers to take the next flight, but only five of us were willing to get off the bird we had.

So two hours later five people were flying out of Port au Prince headed for Orlando. I chose to go on with the crew to Charleston, SC, the aircrafts home base. Ten hours after that, I finally arrived home in Maryland, exhausted after waiting/traveling for 36 hours.

Now I'm clean, fed and rested and wondering what to make of my experience.  Though I'm sure I'll have more observations as I process my experience, here is my first take.

1.  Whatever the source of devastation, people will survive. Virtually every building in Port-au-Prince is broken or destroyed.  Thousands died and were injured.  But most survived.

2.  The role of emergency physicians is in the first few days following a disaster.  Big organizations take time to deploy.  If EPs want to play a role, they must be prepared to deploy quickly.

3.  You can't assume political cooperation.  While most countries want help, you can't assume that they will want exactly what you have to offer.  Take charge people are absolutely necessary, but have to be tempered by political realities.  For example, many amputations were performed early in the disaster.  It was probably necessary and appropriate, but now those that did those amputations are being heavily criticized.  Others who tried to step outside the law and help children are in prison.

4.  You can't assume even all the NGOs will cooperate.  Doctors Without Borders, a fine organization that has done wonderful work worldwide, at times reflected their French origins by demonstrating open antagonism to American doctors and nurses.  Turf wars exist, even in hell.

5.  Speaking of hell, the road there is paved with good intentions.  It's not enough to be willing.  Aid workers must have applicable skills and the support base.  Many people arrived in Haiti hoping to help, but simply consumed resources that were intended for others.  Those wishing to help must have survival skills, their own food, water, etc...

6.  No matter what you do, it is only a drop in the ocean.  There are no saviors of the world in a large scale disaster.  You have to be content to help one at a time. That being said, every person needs to be treated as a human being with their own problem and not as a group.

7.  Be prepared to be changed forever. You cannot look at suffering on such scale without asking some fundamental questions about the meaning and purpose of your life.  Let it happen.  It might be painful and a little frightening, but it's worth it. 
 
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February 1: Hard Decisions
Made a tough decision to return home. The hospital and surg are way down and the big organizations are stepping up. The biggest medical issues now are follow-up. There are thousands of amputees and people with fixation devices that will need to be removed in 8-12 weeks.
 
I talked to a man who said that a funeral director, an LPN, and a dentist were running the CCU at the university hospital. Doctors and nurses finally showed up. Before that they would have 4 IV bags for 30 patients, no BP cuff, no lights at night and no pain meds. The staff nurses were afraid to work in the building at night. It turns out that John Travolta flew them down. This bunch are a part of the Scientology Church.
 
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January 30: When does it end?
Most of the team is headed home today but it looks like I will stay to help run the hospital in Sacre Couer, where we have been working. I anticipate that I will stay no more than a month. It could be less, but no more.
 
I was called to pick up three bodies and found that all three had their hands bound with the same tape. Executed. Left in the street. Their pants were pulled down, to shame not rape.
 
It looks like USA Today may send a crew down to do a story, and the USNS Mercy is arriving soon. The weather is beautiful but rains will start in March. Another disaster looming. When does it end, Haiti? More later. Got to get back to work.  
 
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January 29: In search of the few
It looks like Team Rubicon will be heading home within the next few days. The emergency is over, but Haiti is an ongoing disaster. It is hard to walk away. Big agencies, like MSF, Red Cross and the UN are here, but so many will fall through the cracks. So many helpless. So many fatherless. So many poor. I am heartbroken.

Today I am at a UNICEF clinic in a refugee camp. What we've discovered is that we’re getting into lumps and bumps, sniffles and colds, and we're having a hard time finding the serious injuries. We’re looking for those people, and finding one in a hundred, or even one in five hundred. It’s hard work to find the ones that really need the acute care. They’re out there, by the hundreds and maybe thousands, we don’t know. But finding them is very difficult. They’re laying in refugee camps that are nothing more than scraps of sheet plastic. They are just everywhere.

There are wide open parks here that have now become tent towns. The people who are really injured don’t get up, they’re just stuck in their tent. So we go through and eventually find these pussing injuries, these untreated broken bones. Until you walk the camps, you’ll never find them. If you set up a clinic, you’ll get all of the moms with kids with sniffles while the people with broken limbs lie alone in the camps. They don’t make it to the clinics.

Today, for instance, we found a young woman with an unreduced fracture of her humerus. It was a mid-shaft humeral fracture that wasn’t treated properly at all and really needed an operation. She, like so many others, had had one pass with a health care provider. She even had an X-ray, but her splint was poorly done and it wasn’t doing anything for her arm. But she thought that she had been treated so she was sitting in her tent with an arm in excruciating pain. She’d been that way for two weeks. We’re literally having to find them one by one. They’re not in large groups.

Everyone has been relatively cooperative. There are a lot of doctors and a lot of supplies. It’s not so much turf battles – maybe you get that in the operating rooms because space is so limited. When you get out in the camps, everyone is very, very helpful. The hard part is just finding the people. Sometimes you’re seeing clean, fresh dressings and sometimes their wounds haven’t been dressed at all. It’s a hodge podge.

After I finish with UNICEF I’m going to take a patient over to a hospital in Sacre Couer and I’m going to ask if they will need my assistance after Team Rubican leaves the country. If they do not, I won’t have any more support and I’ll probably have to head home.  

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Caring for the dead in Sacre Coeur
 
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January 28: Potter's Field
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Mark Plaster (R) and Father Jim Boynton ride through Port-au-Prince

When I came into the courtyard of the mission last night it was after dark and everyone was starting to slow down. I approached my new best friend Dr. Michelle, a Pod from Miami, and leaned in to ask a favor. "Can you take a little girl with her finger pulled off," I whispered? She leaned over and quietly answered, "Can you get rid of two dead bodies? They are really starting to stink." She pointed to one of the tents next to where the patients were sleeping. It feels like I'm in an altered reality.
 
Later that evening, we went to the hospital to retrieve the body for Dr. Michelle. The staff told us the body was gone and they had no idea how or where. We went back and asked Dr Michelle and she told us that someone had taken the body and dumped it on the street around the corner. We drove around until we found it. Brother Jim said a prayer over the unknown man. Gunny sprayed off the body with a fire extinguisher to disperse the flies and then we wrapped the body in a tarp and secured it with duct tape. We took the body to the morgue. No one knew his name. Afterward Brad said it was the hardest thing he had ever done. He said, Can you imagine if that was your mother? I know, I told him.
 
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January 27: We're seeing a stabilization, but what about follow-up?

alt"We are right down town in Port-au-Prince today; pretty much every building around us is destroyed. The only thing still standing near us is a church, which is currently housing a local boy scout troop.
 
The effort is starting to see a logical transition right now. At the clinics you’ll get 10 to 20 people walking in with soft tissue injuries – big gaping wounds that are infected – but fewer and fewer people are needing amputations and surgery. I did get a call from a guy in an outlying area who needed a hand surgeon, which we arranged. Other than that, we’re seeing a stabilization. We’re running a clinic today and it’s a typical third-world situation. You announce that you’re available and everybody who has had a backache or a stomach ache for the last five years shows up. As soon as we arrived today, about 200 people queued up. They were very calm and controlled, lots of kids with dehydration and plenty of vague complaints. We’ve got eight treatment stations, 2 or 3 wound treatment stations, a diarrhea station, an upper respiratory station and then whatever else walks up. It’s typical emergency medicine, really. You have to sort through the masses to find the people who are really sick. Haitians can be hypochondriacs just like Americans. They never get to see doctors, so when one shows up who is free, everybody lines up. Generally speaking we’ll run into about a dozen seriously-injured people in a day, but we’ve got to sort through 400 people to find them. We’re going to another place this afternoon where there are supposed to be some very, very sick people. 
 
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USNS Comfort on diversion?
I got my first look at the USNS Comfort, which is off shore a couple miles. We’re next to a landing zone where helicopters are flying in and out, but right now there is no one waiting to go out. The word going around is that the Comfort is basically full and they are now trying to figure out how to bring people back on shore. The army was talking about setting up a 250-bed post-op rehab facility for all of the people coming off of the comfort. They have some tremendous injuries out there, spinal cord injuries and ICU patients, that will really require follow-up care.  It’s going to create a problem on the backside. We’ve heard that the Obama administration has set a timetable for pulling forces out of Haiti – which makes sense – but there is going to be a lot of long-term care that they’ll need to plan for. There are a lot of sick and injured folks here.        
 
Heavy on medical supplies, light on water
We’ve got medical supplies coming out our ears, but they told us when we left the camp this morning that we had no more water. They said they were going to go try to find water for us. I’ve got a bottle on my back and one in my pack, but that’s the end of my personal stores. I’m assuming we’ll find more – we’ve got a logistics expert tracking it down – but we’re getting a little hungry. I had nothing for breakfast and I have yet to eat my Powerbar for lunch. I’m hoping that I’ll get something for dinner.
   
Surgery Transfers
I’ve been taking patients who need surgery to Sacre Coeur (Sacred Heart), where they can receive treatment, since I know the doctors there. I put them in the back of a truck and take them there personally. When you walk into the hospital, you immediately hit an interior courtyard which is set up as a triage emergency area. It’s a big giant mess. A doctor sits out in the middle of the courtyard with hundreds of people around him, sorting through to find the ones that need to go in for surgery. I was able to bypass this, discuss the patient with the doctor, and take them straight inside. Yesterday I ordered my own X-rays, read them and handed them to the surgeon. It made for a very efficient system."
    
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January 26: Where there are no doctors
 
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photo courtesy of Marcello Casal Jr/ABr
 
Yesterday we just drove down the road and found an open area where we could set up a triage station. We pulled out a tarp, some line to hold everybody back, and just let people come through. We laid out our meds on a table and then just worked through the crowd. Most of the injuries were pretty minor but a couple of them were major, broken bones and such. We probably saw 3 or 4 major cases that morning.

Our team is going to places that haven't had doctors yet. A man told us that a week ago he’d told the UN that they needed help out here but no one had come out yet. To be honest, I had no clue where we were. We drove about a half hour into the heart of Port-au-Prince, a very poor area, people living in tin huts and surviving off of Coleman camp stoves. But I also saw some big, wealthy houses around here. Some of them have fallen down. If it was poorly built it fell down and smashed people. The construction is terrible; they don't have any construction rebar, they build with cinderblocks and they only have these tiny wires going through them. Even homes that look well made may only have a thin skin of concrete on the outside. One more aftershock and they may come down.

I haven't made contact with the navy yet. We wanted to get a feel for what we needed and how difficult it was going to be. So far it looks relatively simple. Right now we're just trying to find the people who are most sick. There are a lot of people coming in complaining of back aches that they've had forever, but since there is a doctor here they all show up.

We had a surgery team show up Sunday and they heard [that there was a need for surgeons]. They went to four different hospitals and all four said that they had all the surgeons they needed and refused to give them any space. Operating space is very limited. These guys are working very hard, 8am to 10 at night.

I'm concerned about follow-up. I asked one doc what he was working on and he told me that he was putting on external fixatures. When I asked him who would be taking these fixatures off, he said, "I don't have any clue." When I asked him what had happened to the patient he had just put a fixature on, he replied that she “went back out and lay on the ground." Somebody, someplace is going to have to take that fixature off and they won’t have clear information on when it was put in. We're talking 4-6 weeks down stream somebody has to take over these cases and they're not even in the hospital. A lot of them have been lost to follow up. Like the little girl I saw today: the bandage I put on her will probably be the last bandage she gets.
 
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January 25: Getting to Work in Port-au-Prince
 
“When we got off the plane, Port-au-Prince was almost completely black. There is almost no light here. We unloaded the aircraft ourselves and it was just a giant scramble getting all the bags off. We had bags in seats and the inside of the aircraft was total chaos. It was shocking that we got all our gear off. We were met by a team Rubicon leader named Jake Wood, a 6' 5" ex-marine sniper who was now a medic. On his own, Jake had decided to come down to Haiti and help out. He’d grabbed a couple friends – some people he didn't even know – grabbed some sleeping bags and flew to Santo Domingo, DR. They rented a car and just drove in to Port-au-Prince. They made a connection with a Jesuit Mission and just camped out in the mission yard and started seeing patients as fast as they could. They were cutting off limbs in the field . . . it was pretty chaotic when they first arrived. That's when Jake Wood notified his father back in Michigan that they could use a second wave of team Rubicon. The team coalesced from all over the country – California, Texas, New York – and none of us know the other guys at all. We all just showed up and it's been amazingly well organized. The team leader down here, Gary Cagle, is a medical logistics guy who worked with the U.N. He was able to put together a 501-c-3 in a matter of about four days and he raised about a quarter of a million dollars in order to bring a team down here and get the job done. So they showed up at the airport, we off-loaded all our gear and came over to the Jesuit Mission, everywhere was pitch black. They told us to throw our sleeping bags down on the ground and they’d introduce us in the morning when we could see everybody. All night long I could hear planes coming and going because the runway was so close. I could also hear babies crying, but it wasn’t until the next day that I learned that this was because the Jesuit mission is a refuge for the homeless."

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Rubicon leaders Jake Wood and Garry Cagle in Port-au-Prince


"The Jesuit Mission itself is a gorgeous old Spanish-style building, but it is unusable. It's about to fall down and nobody can actually go in it. It's a tragedy. Everyone is now living and cooking out in the yard. There are about 40 of us here now but there is a whole group that is leaving today, surgeons who have been here for a while and have to go home. People are coming and going all the time. But it's moving into a different stage at this point. We are now seeing wounds that were handled by people 5-10 days ago. I just took care of a little girl, probably three years old, who had her leg amputated traumatically and we were just cleaning up and redressing her wound. Whoever handled it initially didn't try to do a true amputation they just kind of cleaned up the wound and took the rest of the leg off. We've seen fractures – I just treated a guy with a lower leg, tib fib fracture that was never set, never seen by anybody. Somebody just got him some crutches and he's been limping around with an untreated fracture ever since. We're using cardboard and duck tape to stabilize his fracture because it's too late; we can't get it to set at this point. The surgeons at the local hospital operated until 10pm last night and they had another 200 cases waiting for them. There's a lot of open fractures down here, a lot of orthopedic work.

One serious problem down here is the lack of follow-up. Some docs are putting in external fixators, but they are leaving them with nobody scheduled to follow it up. A lot of people are walking around with X-rays and medical records and hoping that at some point somebody will take the bars off their legs.

Today we drove away from Port-au-Prince and found a place to park under some trees. We've got two trucks out here and just set up a bunch of chairs to see people. The people have been very obedient and calm, we just have to make sure we're not passing out food and water. We don't see starvation but people are certainly not happy. But at the same time in Port-au-Prince people are coming back out. They can be seen sitting outside eating and drinking."

 
 

Comments   

# Wanting to help is not enoughDouglas Char 2010-01-27 17:17
Glad that yo were able to get into Haiti. the ned is great as most of us see and hear. What kind of logisitics did you hvae set up before going into country? Many people with good intention nare getting there then finding themselves in over their head and without the necessary logistical support to safely be of much help to the people of Haiti. As you mentioned there are lots of medical suplies but limited water and security, transportation and resupply remain a real concern for many medical teams. Those swho have not deployed to austere areas before should not see haiti as a venue as "their first experience". VOlunteer at home, become part of an organization nthat will provide you wtih ethe training, knowledge you need to be an effective volunteer.
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# ER Doc Springfield, MAJill Griffin 2010-02-04 01:55
Just came back from Haiti. Was going to send in my story but Marc Plaster has summed it up beautifully. Thank you.
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# Many questions to askDave 2010-02-04 20:16
Great report. I would like to see an analysis of the aid Haiti got after the fact to see where the problems were, what we as a community of ER docs could/should have done. Also, a review would be good of what orgs to join and train with to prepare. Prior attempts to join my local FEMA task force ahave not been successful due to intra-ER group rivalry/politic s. Nothing else is around less than 5 hours away. What other options are there?
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# Kudos to Mark Plaster and EP MonthlySteve Griffith, MD 2010-02-11 03:17
Bravo Mark! I worked at CDTI hospital the week before you arrived alongside the great Dr. Michelle as well and I am impressed with how you summarized the experience. You include the good with the bad for a balanced view. I hope your experience and reporting influences others to get out and do the same; there were a lot of us 'everyday pit docs' down there just doing the work that had to be done. Truly, an ocean of pathology and human suffering. I will never forget those dark, hectic days and nights. Thanks for capturing it so well for all of us.
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