Haiti Days for the Penn Team
I don’t think I’ve really outlined our days here in Haiti specifically in terms of our schedule. We round at 630 AM. It is about a 10 minute walk from the place we are staying on the medical complex to the Friendship House where we meet with Alysha. While alarms are set for 600 AM so that we can get dressed and brush our teeth (no running water until 730 AM), typically we are awoken by the dogs barking well before that. As we were reminded when Tom got up sometime between 4 and 5 AM to yell at the dogs to be quiet, the dogs only speak Creole here.
Rounds typically take 90 minutes or so … they are, in some ways, lightning rounds. It is hard to keep track of all the patients, their wounds, their stories, or even their management plan at times. We’ve resorted to labeling their dressings with terms like “OR”, “X” for dressing change that day, and a “Delta” symbol followed by a date for dressing changes at a later time. We’ve started doing that in the OR as well as a way to remind ourselves when to do the appropriate post-op care. It was something I learned from my dear friend John Pryor, MD during his time with the military.
After rounds, we eat breakfast – prepared by Fifi – at the Friendship House. At 830, Derek and I break away with usually Mike for cast rounds before the OR starts around 9 AM (island time). Mike often employs “It’s Okay” anesthesia for the adults and older kids – he must have a soft spot for babies … just kidding Mike. These people are tired of having pain and Mike and Tom have been nothing less than stellar in making that happen (not having pain I mean).
The OR gets going and it is non-stop at about 9 or 930. Turnover times are, no joke, about 10 to 15 minutes. The transport staff carry patients to and from the various parts of the hospital complex. We usually try and do somewhere between 10 and 12 cases / day which often takes us to somewhere around 8 or 9 PM in terms of finishing the day. There is lunch prepared around 230 PM although a Clif Bar does just as well in that time span.
At 9 PM or so, we meet up at the Friendship House and review the day, discuss care plans, and prepare the OR schedule for the next day. Prestige is usually on the table although water at that point is just as refreshing. PHT1 catches up on e-mail, general life issues, and decompresses from a long day.
Working on a Sunday - Finding a Flood
Babak Sarani helps bail out the flooded OR. Photo by Samir Mehta
Today, being Sunday, was really no different. We were asked by the OR staff to try and end by noon given that they have been running hard since the Earthquake and particularly with our arrival – Babak can be a handful :) …
The day started out the same although everyone was slow to rise. When we got to the OR, Dr. Guy (our French Haitian anesthesiologist) was squatting in what we termed “OR #1” (of 2) using a plastic basin to scoop out the 4 inches of water on the OR floor that had accumulated overnight. The water was being dumped into the trash can. The suction canisters were full of water. We rolled up our pants as we tried to help. Derek and I walked through OR #2 to get something only to see a spark. The four prong extension cord which, incidentally, was “taped” together at various locations was still plugged into the wall and was deep enough under water that you would need goggles to get it out. At that point, the comment was made that everyone needs to get out of the water in the OR now and Tom’s reaction was “Why?” followed quickly by someone saying “Electrocution” and then “Oh S…” … Suffice it to say that our rubble soled shoes would have provided very little safety.
We discussed cancelling our cases but the back log was too much. We made wound rounds while the OR worked on getting cleaned up. I forgot to mention wound rounds. During the day, one of the surgeons would break off with one of the anesthesiologists and take some “happy juice” and a dressing bucket to change dressings on wounds throughout the hospital. This would happen around noon and would take about 2 to 2.5 hours.
The OR Back in Commission
By 1030 AM (less than 90 minutes after seeing Niagara Falls – the culprit was the scrub sink which doubles as a waste receptacle and cast sink in between the two rooms), the ORs were ready to go thanks to redoubled efforts by the Haitians.
We only finished three of the five cases we had planned in an effort to accommodate the wishes of our host. Derek and I did a distal humerus fracture with no signs of healing. Once we were looking at the bone, we realized that the fracture was old – not 3 weeks / Earthquake old, but rather previous trauma old … essentially, we were fixing a non-union / malunion of a distal humerus fracture. The patient was not an earthquake victim at all – he was an opportunist. The kicker is that I cancelled him yesterday and I felt bad that we had made him NPO two days in a row (as we were considering cancelling him today). So, instead, we cancelled two of the other patients. I can’t believe we were taken by him like that. And it was unfortunate as had he told us the correct history, his surgery would have been somewhat different. Ultimately, we did the right thing for him, but I would have rather done him later and taken care of the earthquake victims acutely.
Some Time to Decompress
After the OR, we ate lunch. It was clear the team was glad to have some time to decompress. We decided to head to a hike down “500 steps” to see how Cange was able to get water pumped to it. We exited the medical complex through the front gate we had entered one week ago (and had not been outside since). As we stepped outside, I was immediately reminded of the drastically different world that we were in. Across the street (or rather the dirt road) was a bar … I kid you not … with good music playing. The bar consisted of a three plywood walls, a few stools, and a thatched roof but it was bustling. We started to walk down the hill, occasionally passed by a car or truck and a dust cloud making it nearly impossible to see. We were guided by one of the Haitians who works in the Cange medical complex and a 1st year medical student who has been displaced from PoP since the entire hospital (except for one building was destroyed). He told me that the entire 2nd year nursing school class, with the exception of one or two people, were dead.
As we walked past the thatched roofs, the pigs tied to trees, the naked babies bathing with their naked siblings, kids playing soccer with plastic bottles, a boy passed me a deflated basketball – probably the most telling symbol of their life. As I walked by all of this, I was amazed even more by what the PIH team has established at Cange – an infrastructure, daily meals, schooling, healthcare, a society … it goes so much more beyond daily dressing changes and HIV management.
At the Water Pump
Steps down to the water pump
Water pump house
Beverage distributor. Photos by Samir Mehta
Our guide indicated that we arrived at our destination – marked by an outdoor concrete shower where a number of people were bathing. We climbed behind the single family homes (likely holding a few families) and trekked down to a monumental staircase which wound down the mountainside. As we went down, people (mostly Mike) were reminding us that for every step down, there was step up. J … At the bottom of the staircase, we wrapped around some trees and ended up at a concrete wall where there was water flowing down the mountainside. This was their water supply (or at least part of it). There was large pipes (easily the diameter for Derek or Babak to slide into) sitting free that were part of something more that was being done here.
We followed a large pipe for about another 100 yards and ended up at the water pump. This was it … this was how and why Cange had water. We take for granted that we get water – hot and cold mind you – but here, in an area where most people don’t even eat one meal / day – they had running water – all because of a pump locked in a concrete housing that looked way too old to be doing anything effectively or efficiently.
The bottom of the mountain was beautiful … and a bit embarrassing. There were a number of Haitians cleaning their clothes and bathing in the nude in the water. We (mostly the men) simply turned and admired the mountainside while one the females in our party pointed out “It’s like a European beach” or maybe that was Babak who said that.
We started the trek up the steps. I was amazed to see Haitian women balancing pounds and pounds of laundry on their head as they paced themselves up these 500 steps without huffing or puffing. We took frequent breaks to “admire the scenery” – or at least that’s how Mike phrased. Once at the top, we realized we still had an uphill climb back to the medical facility. As we trekked home, amazed by what we just saw, the people of Cange were wonderfully receptive – speaking to us in French and Creole – saying things I simply had no idea what they meant.
Some of us decided to bypass the front door and get a feel for the area we could see from the top of the hospital – near the OB ward – where there were fruits and vegetables being sold. Right by the front entrance of the hospital was the “Distributorship”. We bought two cases of Prestige and one case of Coca-Cola (the 500 mL in a bottle old school kind). As we were buying, Mike realized that the guy who had been getting this for us (a volunteer from the States who left a day or so before nicknamed “Brick”) had been taking a cut of the cost of the drinks. Nice. Of course, it serves us right to trust someone named “Brick” to make a beer run for us.
Where Should the Patients Go?
The day wound down with a taped discussion of what to do with all these patients. The taping was done by a film maker doing a documentary on PIH. The discussion was very real though … where should these patients go? Some of them are not from Cange, some have no homes to go to, some have no one to follow-up with, some have no resources to do dressing changes or physical therapy. Ultimately, the decision was made to place the patients into three categories – 1) closed fractures in casts or treated with internal fixation (not many), 2) open fractures requiring wound care and in external fixation, and 3) non-ambulatory patients. Despite trying to discharge patients, some would not leave as they have no where to go. Others desperately want to leave like the mother of one of the kids in pediatrics who has ten children to raise in PoP and can not stay with her son.
Obviously, we came up with no answers or solutions.