Haiti Earthquake

My first day in the project and I know already that I am going to love it here!  On arriving at the ITFC (inpatient therapeutic feeding centre) I took a moment to speak with all the staff and mothers present, explaining to them who I was, why I had come and also about the blog I would be writing and why it was important.  I finished by saying that over the next 3 months I hoped that they would welcome me as a member of their families here in Haiti.  The most incredible thing happened; one after another the mothers and staff kissed my cheeks and wrapped me into these big hugs, the kind you almost never get from strangers back home.  I feel as though they have already given me their love and respect and now it is mine to protect, and hopefully grow.

I’m getting ready to leave. I’m trying to explain everything I know about how the hospital functions, and where the hiccups usually occur, to my successor. It includes the progress from where we’ve evolved since I arrived, to the nascent plans of what we?re trying to accomplish next. And I’m trying to verbalize all the details, orthopedic and psychosocial and otherwise, of our almost-100 inpatients.

When I arrived, there were about thirty. Truthfully, most of those are still with us: the nature of serious orthopedic problems is that they take a long time to heal. These are the patients for whom I know not only their names and pathologies, but also their families and moods. I can say I’ve personally witnessed clinical improvement in some, like “Bobby” who is strong on his crutches (but still recalcitrant in extending his knee), and nine year-old “Rebecca” whom I discharged today, walking firmly on her healed femur fracture. I think her limp will soon hardly be noticeable.

“Dearie” finally had her skin graft today after many days of waiting: hers was particularly large. I found her crying this morning about it. She is sweet but always sad, at 19 years old, she lost an infant in the earthquake and has no family to help her. I think she despairs for her future: as her wounds improve and she walks more easily (no longer needing crutches), she fears being well enough for us to discharge her. She has nowhere to go and, I think, no way to support herself. Could healing be more bittersweet?

Since my arrival, we’ve added tents and beds, and more tents, and more beds. Most wounds are no longer infected. Some have had skin grafts. We’re starting to talk about taking people out of traction, or taking off external fixation sets. We’re discussing weight-bearing and walking. But also: non-union, mal-union, infection. The phase of the emergency has changed. Tomorrow will be the first set of fitting sessions for amputees who need prosthetic limbs, through another NGO.

From thirty patients to just-under a hundred. We opened a Rehabilitation service, where patients need less intensive medical care, and more intensive physiotherapy. There are more patients than will fit in the beds available there. We did grand rounds there this afternoon: it is rather a marathon.

I joke that I am kind of like the Orthopedics resident: trying to keep things moving on the wards, understanding diagnoses, filling out paperwork, running around chasing things that need to be chased, without being much in the operating room, or deciding on the course of therapy. I have learned a lot. Orthopedics wasn?t my forte before this.

I have to admit that for the more recently-arrived patients, I am less able to keep their stories separate and straight. There are several young men with fractured femurs – now was that from a fall? Or a car accident? Or since the earthquake? I cannot see their X-rays in my mind’s eye when the patient is in front of me. It’s hard to do a good job telling the story to my colleague when I can?t keep the details straight.

But for others I can recount their medical history without checking my notes: one young woman who is a model patient, has a perfect external fixator, no pain, good technique on her physio exercises, and a perpetually sunny disposition.

Today I also failed to contain my frustration because somehow, a little girl with rosebud mouth and alphabet barrettes had been inadvertently discharged not once, but twice, when the intention was to hospitalize her for IV antibiotics for her potentially infected plate-and-screws that hold together her femur fracture. Her treatment has been delayed for four days as a result. It’s time for me to go. My patience is too thin.

Much is left to be done. We need a proper emergency room with emergency physicians, if we want to call ourselves a trauma hospital. We want to expand to have a general paediatrics department. We should develop to have abdominal surgery capability.

Not long ago, this was a hospital in the middle of the road.

After 4 previous missions I still find myself in the Toronto airport with butterflies in my stomach. In the air flying over Haiti for my first time, my first thought is how calm thing look down below, untouched, I took a moment to admire the colours of the Caribbean city which will be my home for the next 3 months. As the plane descended I was horrified to see that the colours I had been admiring were instead the plastic sheeting people had used to construct these tent cities so numerous and huge that they were visible from thousands of feet in the air. It is estiimated that 2.1 million people are living in the streets of Haiti, either because their homes were damaged or destroyed or because they are too afraid to return indoors. Life’s difficulties are nothing new for the people of Haiti, but I am struck by the fact that prior to the earthquake most Haitians rented, meaning that even if they had the tools necessary, these homes are not theirs to rebuild. The land where their previous homes stood is not theirs to use for the rebuilding of their lives. There is a lot of discussion about the coming months and the weather they bring, the small rains we are having now are wreaking havoc on the tent communities, how will they survive the true rainy season? Or worse hurricane season?

I have finally learned that I will be working in the city of Carrefour, which melds into the southern border of Port-au-Prince along the coast. Only a few kilometers from the epicenter and with a population of almost 1 million, Carrefour was in many ways devastated by the earthquake. I will be responsible for MSF’s nutritional program in the region. As a population who has always been at risk for malnutrition, the force of the earthquake seems to have tipped the scale. MSF is taking a proactive approach to malnutrition, as my colleague put it, treating the indirect consequences of the earthquake. My role here finally clear, briefing finished, I begin tomorrow in Carrefour, what will I find there?

Read my bio here!

In our first week of medical school (more than 10 years ago), one of the earliest anatomy lessons was for us to memorize the roots and branches of the brachial plexus. (The nerves exit the spinal cord at the neck, coalesce into a web and gather into new configurations that become the nerves that travel down the arm to supply muscles, for movement, and skin, for sensation.) It’s complex. I, with my classmates, learned it by rote, passed the exam, and honestly, haven’t thought about it much since then. My colleagues who chose hand and upper-limb surgery are intimately involved with the radial nerve. The neurologists, I’m sure can trace out the branches. For me, as a generalist, I usually only need a passing knowledge. Is this injured patient neurologically intact? Almost always, the answer is yes (but I always check).

Wow, now I have a new appreciation for the radial nerve and its vulnerability. We have quite a few patients with radial nerve palsies (ie. injuries), so now I am quite used to identifying the syndrome: drop-hand, with difficulty extending the fingers and wrist, and difficulty with supination (turning palm up).

What’s interesting is the various levels of injury that have occurred. The most common is a radial nerve injury where it passes through the spiral groove of the humerus: often with a midshaft humeral fracture. One of our patients doesn’t have a humerus fracture, but you can see the scar on the medial aspect of her left upper arm where she had a laceration, exactly in the crucial spot. Sadly, her right hand is also badly crushed; I hope she will again use her right thumb and index finger, perhaps the middle finger, also.

Another patient was a man who, during the earthquake, was trapped in an awkward position trying to protect the baby cradled in his arms. Tragically, the baby perished, as did his wife and older child. He had a right drop-foot (peroneal nerve palsy from compression at the fibular head) and a left drop-hand, with a scar on the back of his wrist. He told us it had been a deep laceration that had since healed over. So, thinking that it had also cut his extensor tendons (of wrist and fingers), they did some exploratory surgery to look for the ends, in order to sew them back together. So many weeks after the accident, the ends risked being difficult to find since they can retract considerably. I joked to the surgeons that the tendons might be in Miami by now.

The extensor tendons, though, were still firmly in Haiti, intact. His problem was neurologic: a radial nerve palsy, possibly compressed in the forearm or elbow when he was trapped. “Maxine” is a little girl, nine years old, with round cheeks and a toothy grin. She had a compartment syndrome of the right forearm (as “Bobby” did of the leg). Her fingers are curled up in full flexion. We put her in a volar (palm-side) splint to prevent contracture at the wrist. There is no movement there at all. She is very tight in the elbow, too. I assume that her radial nerve injury occurred because of the increased pressure in the forearm; the elbow stiffness might just be from prolonged immobilization. The other possibility is that she has a concurrent injury more proximally, before the nerve branches to the triceps. The principle of neurology is always: where is the lesion, what is the lesion, which sounds easy but is (I think) difficult.

And there are others. One patient reportedly had some concrete fall on her shoulder, with axillary nerve dysfunction: my theory is that it pulled at the nerve roots coming from the vertebrae in the neck. Another of our patients, who is very depressed, had a shoulder dislocation for six weeks, which is now in the right position but with a very loose joint capsule. She also has an associated radial nerve palsy, probably at the level of the brachial plexus.

The good news is that the prognosis is fairly good. Peripheral nerves (as opposed to spinal cord) can repair themselves as long as the nerve sheath is intact to guide the way. Already, you can see the beginning of some wrist extension where before the hand flopped uselessly. Physiotherapy will help. And time is a great panacea. Nerve grows slowly – something like a millimetre a day – but it does grow.

Most of our patients are women. I’d say they make up 80% of our most serious fractures. The earthquake struck at 16h50 (4:50 PM) on a Tuesday afternoon  and apparently the most vulnerable were adult women at home, preparing the evening meal.

Among our patients who have been with us the longest are a group of young women in their early twenties. The core group is four: two with femur fractures in traction, one with a tibia fracture just below the knee, and one in an external fixation set for her tibia-fibula fracture. Then there are a few others, of the same age, with similar traction sets or external fixations, who round out the group. But the four are inseparable: when we started moving patients from the orthopedic hospital to the rehab (physiotherapy) service, we had to move them as a unit.

I call them M’s girlfriends. Their eyes light up at the attention paid to them by M, the attractive trauma surgeon who was one of the first team members to arrive after the earthquake. He has been involved in their treatment from the start. He teases them about when they will be well enough to dance with him. And when they moved to Rehab and they saw him less often, they insisted to me, tell him to come visit us.

The ringleader is N, who has a tibia fracture just below (but not involving) the joint line, undisplaced. She gets dressing changes under anaesthesia about every 5 days for the wound behind the knee. She is overflowing with life: talkative, mischievous, shining eyes and luminous smile, who wears her emotions like banners. Last week M told me she refused to talk to him on his most recent round: I said, she’s playing hard-to-get so next time you come begging, and with flowers.

I think they spend their time chatting and gossiping. A few can get around on crutches (as opposed to those confined to bed because of their traction sets), so they sit under a tree outside and gossip. One has a baby of 6 months, who is passed around the room and fawned over. Last Sunday, a hairdresser stopped by and must have done a booming business, because when I saw M’s girlfriends on Monday morning, they all had new matching coiffures.

Last week I asked them if they would consider moving indoors from the tent. The rains are starting. The Haitian doctor said, sure, they won’t mind: the roof of our Rehab building is aluminum sheeting, not concrete. No! M’s girlfriends cried in a unified, horrified voice: there are still walls. The walls are concrete and they will fall on us.

Well, yesterday M said his goodbyes to the girlfriends. He is exhausted and heading home. I think it was emotional on both sides: from the hospital on the street and operating under a tree to, soon, being able to remove their traction and learn again to walk. But he couldn’t play favourites. One burst into tears: why must everyone leave? she asked. Wendy, are you leaving? (Yes, chérie, I’ll leave in two weeks, but new people are arriving with new energy to continue with you.) There was an individual photo with each of them; none of the core four were left out. And when he left, he said, Wendy, please look after my girlfriends.

Aujourd’hui, une organisation faisant des prothèses est venue voir une de nos patientes. Ils sont venus tester la prothèse qu’ils venaient de lui fabriquer. Cette patiente est dans la jeune vingtaine. Lors du séisme, elle a perdu son bras gauche et sa jambe droite. Elle voulait faire son cours d’infirmière…infirmière, comme moi. Cette organisation de fabrication de prothèses, touchée par son histoire, a décidé de lui offrir les 2 prothèses. Aujourd’hui, c’est vraiment le cœur gros que j’ai vu cette jeune fille enfiler pour la première fois sa prothèse de jambe. Je ne sais pas ce qui m’a touché le plus…son regard/ses yeux, son sourire, ou l’espoir qu’on ressentait tous dans ce geste d’offrir une nouvelle jambe. D’offrir une nouvelle chance de repartir dans la vie. Son regard, je l’ai immortalisé en prenant une photo…et comme ce moment ne s’explique pas (ou plutôt je n’arrive pas à trouver les mots pour le faire), je veux les partager avec vous …

Mickey, cette garderie transformée en hôpital, m’apporte chaque jour un peu plus que la veille. Ces derniers jours, j’ai eu la chance de partager les premiers pas de plusieurs patients. Un pas, ça ne signifie quasi rien pour nous tous. Chaque jour, on marche d’un point à l’autre, pour y revenir, y retourner…on ne se rend jamais compte de la chance que nous avons chaque fois de pouvoir mettre un pied devant l’autre. Ces derniers jours pourtant, j’ai vu plusieurs pas qui veulent dire beaucoup plus. Des patients alités pendant 1 mois, ayant perdu leur maison et plusieurs de leurs proches, recommencent tranquillement à marcher. Certains me disent même « enfin », enfin ils peuvent marcher de nouveau. Réapprendre, avec des béquilles, des marchettes, des cannes…mais marcher. Toujours avec ce grand sourire aux lèvres, cette fierté d’avancer. Tout le monde a vécu de durs moments ici, des pertes, de la souffrance, des questionnements face à cet inconnu soudain. Mais aujourd’hui, tout le monde partage ces premiers pas. Je n’aurai jamais ressenti autant d’émotions qu’aujourd’hui face à ce nom, qui prend une toute autre signification pour moi : Mickey.

The other night I was in charge of the getaway car. So there I was, at three in the morning, sitting in the moonlight,  swatting at mosquitoes, with three cars pointed in the right direction. The keys were in the ignition. I was trying to keep the drivers awake in case we needed to get going in a hurry.

No, not a robbery! We were doing a distribution of ‘non-food items’, meaning various things that someone who has lost their house might need to live: tent, blankets, bucket, soap, cooking pots, etc. This is a city of refugees, now. (Technically, not refugees because they have not crossed an international border. They are more accurately called ‘internally-displaced persons’, or IDPs.)

And because these are now valuable items in desperate times, distributions are difficult because of the security risks. We want the things to reach those who most urgently need them, not others who might sell them or steal them. And the stock you bring is limited in number, so you need to limit somehow the people who receive, despite nearly infinite need. Rioting and stampedes are a real possibility.

So it’s delicate. There is some discussion and planning with community leaders. But secrecy as well, with some element of surprise so that the crowds don’t swell out of control. Tight security. Strict lines. And this one was done at night so as to reach those who would leave in early morning for their jobs.

And me: the lone medical person on the team in case someone gets hurt. And in charge of the evacuation cars. I joke that it’s the opposite of a hospital project, where the medical staff get all the glory and logistics’ role is forgotten, as long as the lights are on and the water is running. In this case, logistics has all the action, and I’m just support staff.

In the end, then, I saw nothing. Four hundred households received their kit, no one was hurt, and we left efficiently but not with tires squealing.

It’s hard to sleep because of the aftershocks.

There were two tonight, both fairly strong, in quick succession. Very much not cradle-like, they shudder and rock one out of sleep. In darkness, heart beating, wondering, *now*, should I panic’ But it’s over before any answer comes.

There was another big one last night, which was a jolting, falling sensation. And one this morning while we were doing rounds at the hospital, which caused one of our patients, an amputee on crutches, to lose his balance and fall.

It’s not quite a daily occurrence, but certainly it has been  happening several times weekly. The feeling of helplessness and unpredictability is petrifying. But precisely because there is nothing much to do, one just carries on.

Marie-Michèle Houle et Jerry ... quelques jours après mon arrivée! Nous regardions les photos qu'il avait prises avec mon appareil photo.

Je travaille actuellement dans un centre de prise en charge de soins post-opératoires. Les patients ont besoin d’un suivi pour différents  problèmes opératoires. Par contre, nous devons parfois garder des patients en observation dans le centre pour d’autres raisons de santé…ou parfois même les référer. Nous avons environ continuellement 60 patients de tous âges. Des enfants, des ados, des jeunes adultes, des adultes, des personnes âgées… c’est vraiment beau de voir cette cohabitation. Car même si leurs histoires sont différentes, j’ai l’impression de voir se construire une petite famille, tous unis face à une même tragédie. Notre unité d’hospitalisation est installée dans une garderie qui s’appelle Mickey Mouse. C’est divisé en plusieurs sections, mais dans chacune de ces sections, il y a un petit quelque chose qui la rend unique…

J’ai plusieurs amis dans cet hôpital… beaucoup de gens adorables et surtout forts…plusieurs héros. L’hôpital prend tranquillement de la couleur, de la joie…

Pour la première fois cette semaine, mon ami Tom a pu marcher avec des béquilles depuis son amputation. Tom a 7 ans. Il a été amputé de la jambe droite et il reste à l’hôpital avec sa petite soeur de 12 ans. Chaque jour, sa maman qui a 1 enfant de 1 mois vient passer la journée avec eux. Tom a été mon premier coup de foudre en Haïti. Souriant et coquin, on se fait toujours des clins d’oeil et des “good” (pouces en l’air!). Cette journée là, quand il s’est déplacé avec ses béquilles multicolores, tous les gens l’applaudissaient dans l’hôpital. Les malades dans leur lit qui ne sont pas encore rendus à reprendre la marche, mais qui encourage beaucoup ce petit bonhomme plein de vie! Il souriait tellement, les bras lui tremblaient, et je dois avouer que je n’ai pas souvent vu Tom dans son lit cette journée-là… maintenant qu’il pouvait se déplacer.

Il y a une dame aussi qui me touche beaucoup (tout le monde me touche, mais…). Elle est depuis 3 semaines dans le lit 1. Elle ne sort jamais de son lit autre que pour aller en salle d’opération pour faire son pansement sous anesthésie ou pour changer les draps de son lit. Cette femme est une des quelques personnes amputées qui se trouve dans notre centre. Elle est âgée, elle doit avoir près de 70 ans. Il y a toujours une odeur nauséabonde quand on passe au côté de son lit parce que sa plaie est infectée. Malgré tout ce que nous avons essayé, la plaie de l’amputation ne guérit pas du tout. Son pansement a toujours un écoulement…senteur de chair pourrie. C’est difficile à expliquer. Elle ne veut à peine manger…ses enfants doivent la faire manger, car elle est trop découragée et dépressive. Et vendredi passé, les médecins lui ont appris que nous allons devoir la réopérer pour couper un peu plus haut, au-dessus de son genou. Samedi, je n’en pouvais plus de voir son regard désespéré, son regard d’appel à l’aide. J’ai donc décidé que nous allions la sortir dehors. Qu’il était temps qu’elle voit le soleil, qu’elle change d’air. Elle ne disait pas grand chose, mais elle a accepté. Donc en chaise roulante, nous sommes sortis, devant la garderie et nous y avons passé 10 minutes au soleil. Elle m’a parlé un peu finalement…et même les silences de ce moment étaient précieux. Son visage a repris un peu de vie et elle s’est mise à s’étirer un peu le cou pour voir les gens dans la rue. Aujourd’hui, elle a accepté de faire l’opération et elle a repris le sourire…

J’ai aussi une petite princesse!!! La jolie! Jessie doit avoir environ 10 ou 12 ans. Elle reçoit de la visite de sa famille, cousins et cousines, mais je n’ai jamais vu sa mère ni son père. Elle a une fracture de la jambe et une grosse plaie. Elle aussi a une petite infection de la plaie…au début, elle ne parlait pas beaucoup, mais tranquillement, elle s’est ouverte. On lui a donné une barbie qu’elle tresse. Elle est tellement gênée…

Il y a aussi une dame de 31 ans, Marie-Soleil. Lors du tremblement de terre, elle a perdu sa petite fille de 11 ans. C’était sa seule enfant, car elle et son conjoint avaient beaucoup de difficulté à réussir à faire un enfant. Sa fille était pour elle un miracle. Et le jour du tremblement, elle était à la maison avec sa fille. La maison s’est écroulée sur elles, mais des voisins ont sorti la maman des décombres…mais on n’a pas retrouvé sa fille. Elle avait des abrasions partout sur le corps, un peu défigurée même et une fracture du bassin. Au début, elle était seule…seule, car son mari n’arrivait pas à venir la voir. Il l’aimait tellement que de la voir dans cette situation le torturait, en plus de la douleur de la perte de sa fille unique. Tranquillement, l’équipe a travaillé avec elle et son mari pour les aider à se retrouver. Aujourd’hui, ils sont ensemble dans cette épreuve… elle n’a plus rien. Elle a perdu toute sa famille… il ne lui reste qu’un oncle, un frère et une soeur…

La nature humaine est ainsi faite que nous sommes portés à oublier… nous finissons souvent par oublier. Et ici, nous sommes portés à oublier que la maladie et les accidents continuent de se produire. Que tous les soins ne sont pas nécessairement reliés au tremblement de terre. Du moins, j’avais un peu oublié que les accidents continuaient.

Ce matin, un accident m’a fait rappeler… rappeler que d’autres évènements continuent de se produire, mais aussi que la vie est fragile. Ce matin, je me suis rendue à la base (bureau) d’où je quitte chaque matin. à mon arrivée, je dûs partir d’urgence, car il y avait eu un accident sur la route et des blessés se dirigeaient vers l’hôpital. Je ne sais pas exactement ce qui s’est passé sur la route, mais je sais ce que j’ai retrouvé à l’hôpital… environ 8 patients étendus sur de petits matelas sur le sol, des cris, des pleurs, du sang, beaucoup de sang. Des médicaux qui courent… les patients étaient vraiment graves. Un homme avait toute la jambe ouverte, on pouvait y voir la chair et les os…l’autre avait du sang qui sortait par l’oreille, il vomissait du sang par le nez et la bouche et avait des coupures ici et là, il était semi-conscient et répétait toujours son nom… une femme ayant plusieurs abrasions avec son bébé de 1 an à ses côtés qui pleure… je ne peux pas me souvenir de tous ces gens, mais quand je referme les yeux je vois du sang, beaucoup de sang. Je revois cet homme qui vomissait du sang… j’ai quitté avec lui en voiture pour faire le transfert dans un hôpital plus spécialisé pour ce type de trauma, ce type d’urgence. Le trajet a duré environ 30 minutes, la circulation était dense. J’avais l’impression qu’on allait jamais arriver… je continuais de répéter à cet homme que nous étions là, avec lui, ensemble. Que nous allions arriver, de ne pas lâcher. Quand nous sommes arrivés à destination, je lui ai dit que nous y étions, il a ouvert les yeux et m’a regardée… cet homme, il avait mon âge. Je ne sais pas si demain il aura encore mon âge, car le fil de sa vie était encore plus mince que jamais quand je l’ai quitté.

Des expériences comme celle-ci n’arrivent pas tous les jours…