In January 2004, I made my first trip to Haiti, spending a week in the tiny village of Dos Palais in the Central Plateau. It was an eye-opening experience that stoked my desire to return in a clinical capacity, despite a fundamental gap in knowledge re: loco-regional disease processes and an intimidating lack of language skills. In 2005, I participated in a one-day clinic in Dos Palais overseen by Zanmi Lasante (aka Partners In Health, founded by Dr. Paul Farmer) and was impressed with how the team was able to "power through" (as ZL's Dr. David Walton so aptly put it) nearly 400 patients in 8 hours. This experience prompted me to enroll in a weekend crash course in tropical medicine in Manassas, VA, in 2006, which gave me something of a comfort level with the inherent medical problems that a clinician would face in Haiti.
Fast-forward to January 12, 2010 and the seismic devastation that struck Haiti. Now, at this point in my medical career, I have been in private practice as a radiation oncologist for nearly 20 years and, despite juggling a heavy patient load and a variety of other commitments, I was even more intrigued by the possibility of going back to Haiti. Urgent emails began to appear in my box from a variety of organizations re: the need for surgeons and anesthesiologists in the immediate aftermath of the quake. Once again, I could only look on with envy as those with completely different skill sets came to the fore and answered the call.
Sometime in April, I received an email from the Dooley Society, an association made up of doctors and dentists who graduated from my alma mater, the University of Notre Dame. The Society is named after Dr. Tom Dooley, a former ND student, who served the medical and humanitarian needs of the people of Southeast Asia, dying prematurely from melanoma in 1961 at the age of 34. This email bulletin was more generic and called for "physicians and nurses" to work in the Hopital Ste. Croix in Leogane, the epicenter of the quake. Notre Dame has had a presence in Leogane for many years with their Lymphatic Filariasis Haiti Program, and took on the task of staffing a field hospital and clinic in conjunction with an NGO (non-government organization) called World Wide Village. I emailed the coordinators and advised them that I was a specialist in cancer care but could certainly function as an internist, had been to Haiti three times and was willing to work under any conditions. Much to my delight (and surprise), I was accepted as a member of "Team 18" scheduled to serve from May 15 through May 24. I arranged to leave Leogane on May 22 to be sure that I was back in my own clinic at the Thomas Johns Cancer Hospital by the 24th. Exhilaration melded with trepidation. I couldn't believe this was happening.
BEING THERE: Team 18 started getting acquainted via email in the days leading up to departure for Haiti. There were 16 of us: eight doctors, six nurses, a nutritionist and an orthopedic technician. The diversity of the group was intriguing. The docs consisted of a psychiatrist (the team leader), an orthopedic surgeon, an OB/GYN, an ER doc, a senior internal medicine resident, two pediatric anesthesiologists/intensivists and myself. We hailed from NY, NJ, VA, NC, MO, MN, KS, IL, IA. Three of us were ND alums. Several of our nurses had ICU experience, including neonatal care. We met as a group for the first time amid the chaos that defines Toussaint L'Overture Airport in Port-au-Prince on Saturday, May 15. The main terminal had been damaged in the quake, necessitating a somewhat makeshift passport control and baggage claim. Most us carted large plastic tubs filled with medical supplies that we had scavenged from numerous sources including dressings, gloves, empty medicine bottles (we manned the pharmacy, as well) and much needed medications. Thankfully, staff drivers from Residence Filariose, which was to be our home for the duration of our stay, met us at the airport. After loading our supplies and personal belongings into the Land Rover and pick-up trucks, we began the journey to Leogane.
Now, bear in mind that Leogane is only 18 miles west of PAP but the thick traffic and typically variable road conditions made for a 2.5 hour trip in stifling heat. The city was clogged with people, some looking busy, others just looking. Many buildings were reduced to chaotic piles of rocky debris, although a surprising number somehow remained upright and functional. Random piles of stony rubble appeared amidst twisted rebar. The air reeked of garbage and was barely tolerable. Assorted tent communities appeared amidst the ruins of neighborhoods. Many portions of the roads were buckled from the shifting of the earth below. In a country where life is generally miserable, things had actually gotten worse. It was a very quiet, sobering ride.
The streets of Leogane were significantly worse than those of the capital. We had been told that 90 percent of the buildings in Leogane had been destroyed. I found that to be an exaggeration, but not to an improbable degree. Still, there were people on the streets, trying to get through yet another difficult day. Our 3-vehicle caravan sped through a large solid metal gate onto the compound grounds, winding through a shantytown of tents and hovels cobbled together from random pieces of sheet metal, cardboard, wood and plastic tarps. We were barely acknowledged as we pulled through another gate into Residence Filariose. This facility was designed by the architecture students at Notre Dame and sustained zero damage during the quake. Funding for construction of the facility was through the Bill and Melinda Gates Foundation. The director of RF, Sean Farrell, ND'77, was non-medical and more of an organizer and accounting type. We were all assigned rooms, 2 or 3 to a room, which included mosquito netting, with a shared bathroom. Showers were at ambient temperature but it was so hot that a cold shower was actually refreshing. Water was purified on site with maintenance of the system being our own responsibility. A refrigerator in the back room was stocked daily with soda and bottles of frosty Prestige beer, the local pilsner, for $1.50. Dinner was the only meal provided and was usually tasty and bountiful with lots of rice and veggies with either chicken legs or goat meat as a protein source. We had been told in advance that we were on our own for breakfast and lunch. Nabs, Pop Tarts, Power Bars, etc. were in abundance.
After stowing our gear and unloading our supplies, we met with the members of the outgoing group, Team 17, who gave us the lowdown on managing the hospital and the clinic. Clinic was open from 8AM until all patients were seen, usually between 3 and 4PM, except Sunday, which ran from noon until 4PM. We were advised that Monday was usually the busiest day. Interpreters would be assigned to the clinic docs and would be available in the hospital. The team would be supplemented by one or two Haitian docs and several Haitian nurses. We would need at least 2 doctors, preferably 4, to run the clinic. Two of our own nurses would run triage, taking vital signs and jotting down a brief HPI or history of present illness. The hospital functioned on 12-hour 7-to-7 shifts. At least one physician was expected to be in house on call every night. All of this information was processed by us rookies followed by some discussion about how we would organize ourselves. Team leader, Dr. Lori (no surnames here), adroitly delegated the workload to everyone's relative satisfaction. Sunday would be our first taste of action.
Some folks dragged themselves out of bed early Sunday morning for Mass in Leogane while most grabbed another hour or two of sleep before we assumed responsibility for managing the hospital and the clinic for the next week plus. The hospital itself was a modern field unit, donated by a Canadian businessman (so I'm told), and opened in March. (NOTE: Leogane's only facility, Hopital Sainte Croix, had been closed for the past 2 years. In a perverse twist of fate, the earthquake re-established accessible healthcare for the people of Leogane and the surrounding area.) This modular facility was air conditioned with six pods, three on each side, branching off of a central corridor. A guard was posted at the door to maintain some semblance of order. Upon entering the hospital, the ER was the first unit on the right side followed by Central Supply and the OR. On the left side, the first pod was a nutrition program manned by a separate, not particularly friendly, NGO. This was next to the OB/GYN room, with the final unit being the in-patient area. The patient-care areas (ER, in-patient) each had 10 cots with another 7 in the OB room, including two incubators. The OR had two tables where two surgeons could operate simultaneously, much like you would see on the old TV program M.A.S.H. Central Supply had large amounts of some relatively useless things and was frustratingly lacking in supplies of far greater importance, like IV fluids. Most medications were stored in a separate pharmacy, which was adjacent to Residence Filariose. In addition to the ND/World Wide Village facility, Medicins Sans Frontiers or MSF, better known as Doctors Without Borders, also established a presence in Leogane after the quake struck.
As is often the case, people gravitate to what they do best. The ER doc, Dr. Dave, the internal medicine resident, Dr. Derik and the orthopod, Dr. Todd, all set up shop in the hospital. The pediatric intensivists, Dr. Jennifer and Dr. Adam, floated between the OR and the clinic. Dr. Mike, our OB/GYN, parked himself in the OB room, while the non-hospital docs, Dr. Lori and I, anchored the clinic. We each had our own interpreter to bridge the language barrier. Two nurses were assigned to triage and two others manned the pharmacy filling our prescriptions. Another interpreter was stationed in the pharmacy to reiterate the instructions for medication use. Runners were available to bring us water or escort patients to the hospital. Walkie-talkies were in use to communicate between the pharmacy and the hospital or clinic to clarify prescriptions or inquire about the availability of a certain drug (we usually didn’t have it or it was in low supply).
In stark contrast to the climate-controlled hospital, the clinic was a simple wooden frame with mostly open sides and a tattered blue plastic tarp for a roof. Constant hydration was a must in the 98 degree temperatures. Occasionally, a goat or a rooster would wander through the clinic, assessing the situation before moving on. The Sunday clinic was, in retrospect, "Clinic Lite". We probably saw fewer than 75 patients, a sharp contrast to the 300 or more that passed through on Monday. Tuesday through Friday was somewhere in between with 100-200 each day. Several cases were referred directly to the ER or OB for a more refined assessment. Potential surgical cases were likewise referred to Dr. Todd who performed upwards of 25 operations over the course of the week.
Patient encounters were usually quite brief, most no more than 10 minutes from start to finish. Our "office" was a beat up desk with three folding chairs: one for the doc, one for the interpreter and one for the patient. An exam "table" was set up behind a makeshift barrier for more detailed physical exams. Privacy was minimal. We freely consulted with each other re: symptomatology, mystery rashes, medication dosages, etc. It was a wonderfully collaborative effort. No egos. Everyone just wanted to do their best for the patient, just like we would do in our own individual practices. Symptoms of acid reflux were the most common complaint among adults, while rashes and diarrhea the most common pediatric issues. Unfortunately, we had a limited supply of Zantac and ran out of Tums to treat the reflux patients. By mid-week, we had to resort to baking soda and water. It was primitive, at best. Lots of things were treated prophylactically. For example, diarrhea was often managed with albendazole to treat intestinal worms. Patients with waxing and waning fevers with chills were frequently covered for malaria. Many folks presented with itchy, burning eyes, a fairly vague complaint, usually associated with the dry, dusty environment. Early on, we took to rinsing people's eyes with normal saline. In all but a few cases, this was a miracle cure. But as Dr. Peter Drobac said 5 years ago in the Dos Palais clinic, the underlying diagnosis for all of these people is poverty.
We took turns being on call in the hospital. As a non-hospital doc with no in-patient duties for nearly 20 years, I prudently took call with Dr. Dave on Sunday evening. Doctors can be fairly superstitious people. The first question I asked Dave was "What kind of cloud do you have?" "A white cloud", he replied. Simple translation: I have good luck on call. True to form, we had no admissions overnight and got a relatively decent night of sleep before the Monday clinic onslaught.
There were some indelible moments but none was more poignant than on Tuesday evening when a young woman walked into the ER at 8PM in labor. She’d had no prenatal care that could be documented. Dr. Mike delivered a little boy (lapsed memory; I may the gender wrong), who appeared to be-maybe-32 weeks. His underdeveloped lungs struggled for air as our NICU nurse, Callie, and the peds intensivists, Dr. Jennifer and Dr. Adam, worked quickly and efficiently to save their patient. All of the other nurses-Kathy, Jobena, Tara, Beth and Melody-were actively involved as this drama unfolded. And then, the unexpected occurred. Dr. Mike felt another tiny person and delivered the twin, this one a little girl. Now, both of these incubators in tattered Leogane were surrounded by the very best docs and nurses that could be had anywhere. Oxygen flowed, tiny IV's were started, and bundles of clean socks were microwaved and tucked around the babies, who were carefully placed in gallon size plastic bags up to their chests, to keep them warm. Kathy took digital photos of the babies and showed them to the mom, resting off to the side of this flurry of activity. The dad was 24 years old and not sure what to think about all of this. At one point, mom got up, shuffled over to the incubators and held each baby for a few fleeting moments. It would be their only contact in this world. One of the babies died overnight despite round the clock care. The second baby was transferred to MSF and died Wednesday night. Life and death, in the blink of an eye.
Dr. Todd and I both had our own unique shared experience on this trip. Later Tuesday night, I developed a lower GI issue that kept me up most of the night and caused me to miss clinic on Wednesday. I re-hydrated for 24 hours, minimized my food intake and felt good enough to be back in clinic on Thursday. Dr. Todd was hit with the same thing on Wednesday evening. He opted for IV re-hydration in the OR overnight and was stable enough to operate on Thursday. Neither one of us could pinpoint a cause but we both agreed that it was-ahem-a draining experience.
One of the more memorable moments for me occurred on Thursday. One of our neighbors (and fellow St. Michael parishioner), Sandy Strohmann, has a daughter, Tara, who is serving with MSF in an administrative capacity in Haiti. After a couple of false starts, Tara and I connected by cell phone and actually managed to meet each other in Leogane after clinic on Thursday. It was great to hear her perspectives on Haiti and MSF, as we both wondered aloud what was going on back in Virginia. I hope our paths cross again in the future.
BEING HERE: There are so many images, so many people, so many experiences. It's been said that Haiti is beautiful, frustrating, seductive and exasperating…all in the space of an hour. It's true. As we drove to the airport early Saturday morning for the trip home, the devastation became a blur, a record that keeps skipping, a loop that keeps repeating. It seems like there should be a breaking point, where people just give up. Maybe it's there and I just can't see it. Suffice to say that Haitians are a proud and resilient people with a deep faith tradition. Another day dawns and the struggle begins anew. The job of people like you-and me-is to keep that breaking point out of reach, out of sight, and continue to offer help and hope to a country that deserves better.
Thomas Eichler, MD