Opinion :: Guest Opinion
On the ground in HaitiWednesday Mar 10, 2010 Local doctor gives his impressions after serving in an overbooked Haitian hospital for one week
Last week South Ender Dr. Doug Fiero, joined by three nurses and a nurse practitioner, flew down to Hopital Sacre Couer, a 64-bed hospital in Cap Haitien, Haiti, currently dealing with the impossible task of helping over 500 patients. The hospital, run by the nonprofit CRUDEM, out of Ludlow, Mass., has set up a tent hospital to help deal with the demand for aid. The group paid for its own airfare and each traveler used vacation time while away. (For more on the trip read "Local doctor making an impact in Haiti," 3/4/10).
After flying three and a half hours from Boston to Miami, an hour and 40 minutes to Providenciales, Turks & Caicos, staying overnight (only one flight leaves for Cap Haitien daily), a 40-minute hop over the "Old Bahama Channel" to the airport, and another hour ride, we arrived at Hopital Sacre Coeur to find a "mobile hospital" with five wards in tents and three other wards of children and adults, generally with family members living with them. Injuries ranged from amputations, long bone, hip and pelvic fractures, often having external or internal repairs, frequently infected, and not fully healed. There were many skin and soft tissue injuries, including bed sores, infected, and in need of drainage, debridement, surgical repair, and/or skin grafts. There were many scalp and facial injuries. Many previously treated fractures were infected, requiring occasional removal of previously placed hardware, intense antibiotic treatment, and local care. We also had a number of spine injuries, with and without paralysis, which needed to be stabilized surgically in order for these patients to be mobilized, and to prevent the development of bed sores, if they did not already exist.
The language barrier made personal contact difficult. These people seemed very tolerant and appreciative of all our efforts. Their gratitude was expressed through gestures, and through the interpreters. Working with the Haitian earthquake victims was rewarding for us all. I only wish we could learn what is to become of them, to maintain contact. However, we know that there is no way to do this. I think my military training and experience helped me maintain a clinical attitude, and not be personally affected by the suffering I encountered.
Our "team" consisted of a total of 60 health care volunteers, 39 of which were physicians, mostly from the U.S., but with a handful of people from England, France, and Germany. There were large surgical, medical and pediatric teams from Houston, northern New Jersey, St. Louis, Washington, D.C., Baltimore, and our group from Boston. As one of the few general internists, I was assigned to the ICU, located in the main hospital, along with a nurse practitioner trained in ICU and invasive procedures, and two critical care nurses. One of these nurses was born in Haiti, spoke fluent Haitian Creole as her native language, and was invaluable as our interpreter. She was able to help patients and their families understand the medical aspect of our interventions. For continuity, we stayed in our jobs all week.
Our days started with breakfast at 7:00 a.m. and we met with our team at 8:00 a.m. We worked until 12:00-1:00 p.m., staggering our breaks for lunch from 1:00-2:00 p.m. Then it was back to the ICU/Wards until 5:00 or 6:00 p.m. Supper was at 7:00 p.m., then a group spiritual and organizational meeting took place at 8:00 p.m. (Remember that this is a Roman Catholic Mission, although very ecumenical in tone.) After the meeting we would head down to the ICU or Ward for a final check, settle night call, and come back for some quiet time and sleep at about 10:00 p.m. All of us have been through rigorous training programs, and this schedule was no more demanding than that. Everyone was up and ready to go at 6:30 or 7:00 in the morning. In training, and in practice, you do what needs to be done. There is no alternative.
In our 10-bed ICU we saw a steady stream of the sickest injuries and some of the most unstable post- and pre-operative patients. We were also responsible for some of the regular hospital patients who experienced medical complications. Although we did not have all of the equipment, medications and treatments available in U.S. hospitals, we had the essentials we needed to do the job.
Throughout our time in Haiti, we were struck by the durability, determination, and cheerfulness of these severely injured and ill children and adults. The children, of course, were irrepressible, smiling, laughing, wanting their picture taken, cheering us up as they hobbled along on crutches or hopped on one leg. The adults had been through so much that their situation was not nearly as hopeful. They had been injured and bedridden for seven weeks, many suffered from flashbacks of the quake, and some were frightened to be inside buildings, instead preferring the tents. We recognized signs of Post Traumatic Stress Disorder in these people, just has it has been seen in returnees from Vietnam, the Gulf War, Iraq and Afghanistan. Time and effort and ongoing supportive care will be needed to make these people whole and functional again.
Illness and injuries run a course, predictable and unpredictable, from "acute," two to six weeks, "subacute," six to 12 weeks, and "chronic," over three months. Because of the severity of the earthquake injures, with many crush injures, major fractures, head injuries, and with the high rate of complicating infections, healing will be measured in months to years. The high infection rate is probably due to the heat and humidity of the Haitian climate, the extreme contamination of wounds, and the difficulty maintaining hygiene in the devastated Port-au-Prince area. Safe drinking water and proper sewage disposal did not exist in medical facilities, much less in the rest of Haiti.
The injuries we were seeing are now in the "subacute" phase. Intense ongoing effort will be needed for complete healing. Then these injuries will enter the "chronic phase." Here, another equally intense effort will be needed, focusing on rehabilitation, independence, and self care. To facilitate that change Hopital Sacre Coeur and the CRUDEM Foundation are developing a facility to fabricate and fit prostheses, and to train people to do the kinds of intense physical therapy and rehabilitation it will take for them to achieve their highest level of healing and function.
Before the quake, Haiti had a weak and poorly functioning central government. Their health care system was largely non-existent. In order to move to the "chronic phase," both must be strengthened. Help will be needed in establishing an honest and responsible government, rebuilding the capital, Port-au-Prince, and in establishing a health care system, by and for Haitians. In the meantime Hopital Sacre Coeur and many more volunteer health care workers will be needed.
For me, this was a reminder of my time as a General Medical Officer assigned to Japan in 1967-1969, receiving injured GIs from the Vietnam conflict. Army policy was to evacuate wounded soldiers to Japan within days after stabilization in Vietnam. Our task was to do whatever was necessary to get them through the "acute" and "subacute" phases, to then be sent back to duty, or to the U.S. if they needed ongoing or "chronic" care. We saw many of same type of wounds suffered by the people of Port-au-Prince.
As we left, all of us were enthused and buoyed by our work with the Haitian people, and will be looking for opportunities to return. My lasting memories are partly with those who will eventually recover to live a full life, situation permitting, but more so with those destined to struggle for survival in a land of limited resources and potential. As with our veterans of Vietnam, and most recently Iraq and Afghanistan, will their society allow them to reach their best potential, or destine them to continue to struggle to survive with lasting disabilities?
Dr. Doug Fiero, MD, MPH, is a semi-retired physician, living in the South End, and working part time at Boston Health Care for the Homeless Program, as well as the South End Community Health Center, and Roxbury Comprehensive Community Health Center.
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