It is Saturday but we are working a full day. We can tell that the staff here are a bit taken aback at our schedule but they also realize how important it is to their community. Every single one of the individuals who works in Cange has lost somebody due to the earthquake. One of our medical student hosts, Thirry, a 3rd year medical student at Harvard who is interested in Orthopaedic Surgery (smart man), lost his aunt and uncle in PoP, leaving his 10 cousins orphans. He is desperately working with the Canadian and US Embassies to get the kids to his parents in Montreal where he grew up. Of course, this is being met with some resistance due to local beaurocracy but he has a plane arranged for this morning with a small window of leaving.
Photo by Samir Mehta
We need supplies which are in short order as we have been burning through whatever they had in the ORs already. We try to get access to the 1200 lbs of equipment we brought with us and eventually have someone give us the keys to where they are housing the bags we brought. As we walk to depot area, I am amazed at the sheer size of the facility … along with a hospital, the complex has a school for children, a theology school, domiciles for the physicians and staff. In some ways, it is its own society.
We eventually gain access to our supplies. Amy, Derek, and I rummage through the items quickly throwing the things that Malcolm and Azura indicated were absolutely necessary to operate which the ORs no longer had – you know gloves, gowns, sponges – things that we take for granted.
There is a clear transition happening. Of our ten cases today, five were split thickness skin grafts – the real question is, of these grafts, how many will survive. Wound care is a major issue. The wards are beds or blankets on the floor and multiple patients (along with their families) crammed into a very small physical space. Nursing staffing is 1 to 20 or 1 to 30 depending on the site. The staff are doing their best to keep up. A necrotizing fascitis patient has ants crawling on his bed, too obtunded to notice. Our critical care nurses are quick to respond and change his necrotic wound, but there are still physical plan issues that can not be addressed. Pseudomonas is common is most of the wounds … in fact, the fruity smell of the bacteria is notable when it is not present.
What Happens Next?
We have gotten some word that we may be leaving next Saturday. While we are all excited to return to our lives and our families, I can’t but feel some sense of uneasiness about leaving – what happens when we are gone, what will the next team do, will management change, and then what?
Photo by Samir Mehta
We are sitting around after a long Saturday. There is some Prestige on the table. A few bottles are already empty. We are discussing the essential information to pass on to the team that is following us from Duke. As we are talking about everything the hospital here doesn’t have – like fluoroscopy, the ability to get basic labs, instruments and implants, and hot water – we are reminded, yet again, of how lucky we are in the States.
The discussion shifts with Ranu (a 2nd year resident from the Brigham at Harvard’s Global Equity Residency Program who has already spent time in Rwanda) about where to go from here. We discuss the concept of parachute docs –which, in some ways we are – docs who “fly in”, do a bunch of surgery, and then leave. There is little in terms of education or sustainability. It goes to the concept of “give a person a fish and they’ll eat for a day; teach a person to fish and they’ll eat for a lifetime” or something to that effect. In the case of Cange and PIH, it sounds like they have teams following for at least the next several weeks, but what happens after that – what happens when the next wave of infections or non-unions develops. The country does not have the capacity or the infrastructure to deal with these complex issues. Derek volunteers himself. We suggest a “CME” type event to be held in Haiti through PIH to local providers to discuss comprehensive care issues including orthopaedic complications (expected from these injuries), nursing care, physiotherapy, prosthetics, and orthotics. I sincerely hope that this will be a reality moving forward.