Monday, April 19, 2010

City of the Sun

(Photo by Beth McHoul)

As I sat on the back step of our white truck today, a boy of about 10 years of age pointed to the bright orange and red sun tattooed on my left deltoid. The mass of boys surrounding him watched the interaction, straining towards me, en mass, with increasing curiosity.

"Is that a tattoo?" he asked, in a tone of part accusation, part curiosity. In this neighborhood, a tattoo represents a gang affiliation.

"Oui!" I replied, running my fingers across the words printed in the center of the sun. "Cite Soleil," I read as I pointed to the words. They looked at each other, then back at my tattoo.

"Cite Soleil?" the lead boy asked, then looked at his friends. They chatted animatedly amongst themselves. I imagined the topic of their chatter. Cite Soleil? Wait a minute...That's our neighborhood!

"Did you do it with needles?" the lead boy asked again, as he wiped a finger firmly down the center of the sun. The rays smeared slightly. Busted. I grinned.

"Nope," I replied, gesturing like a pen. "With a pen...just a pen..."

The boys nodded at each other, then smiled knowingly. Small brown hands reached to further smear my Sharpie tattoo. One then lifted his sleeve, with great courage, revealing a tiny little deltoid.

"Do me, do me..." he gestured to my tattoo and then his arm. "Cite Soleil...Cite Soleil..." he repeated, gesturing.

The gang tats ruled. Our final tribute to the 'hood.

Today marked our last medical truck run to Cite Soleil, the City of the Sun -- the poorest neighborhood in Haiti, the most impoverished community in the Western Hemisphere, and, according to the United Nations, the most dangerous slum in the entire world. Just a few years ago, this community -- of 200,000 plus people -- was overrun by more than 30 gangs, devastated by extreme poverty, and terrorized by violence and kidnappings. While the poverty persists, the violence has largely subsided due to a permanent United Nations peace keeping presence driving the streets in armed vehicles, an armed bunker in the heart of the slum, and a shoot-to-kill anti-kidnapper mandate. In this hot labyrinth of cinderblock and corrugated metal shelters, expanding peripherally into post-earthquake tent cities, the disaster of 12 January was one more inconceivable burden placed on the bowing shoulders of an already too-impoverished community.

Yet, despite these challenges, it is indeed a community.

At first glance, one is struck by the garbage and pig-filled drainage and sewage canals that cut through the heart of the neighborhoods, the crumbling cinderblock shelters,and the sheer agonizing poverty. Gaunt, dark skinned Haitian children predominate, unusual reddish hair on their African features a sign of Kwashiorkor -- severe malnutrition, reflecting desolate poverty. The life expectancy in this slum, due to lack of access to the basic necessities of life -- food, water, shelter and health care -- hovers around fifty years.

But, just as these thoughts begin to overwhelm your psyche, a child appears, and then another, and they grab you by the hands. You look down into large brown eyes, alive with gigantic smiles. You overlook their sometimes grimy nails, and the occasional telltale bumps between their fingers indicating chronic scabies infection.

"Hey, you!" they say, as they try to pull you along down their street, perhaps to their home, with great excitement.

"Food!" they demand, pointing to their empty bellies.

And then, if you refuse them, "Water!"

They are sincere in their requests. For they are truly hungry. And thirsty. If you again refuse, they then progress to your baseball cap, politely requesting it. Upon your refusal, they might then point to your watch. The more street-wise boys undertake a more intense, imploring negotiation about why they are in need of a watch, despite their obviously rat-race-free life. And, you again refuse. So, when they finally decide you have nothing to offer -- except medical care...and a smile -- they shrug, smile back, grab your hand, and decide you are still a worthy friend.

And you observe first hand how difficult it is to be this poor. To be starving. To live without clean water. Or electricity. And now, without safe shelter. Yet, despite these profoundly gaping holes in their resources, you will watch with bemusement at their great human resourcefulness. A small child builds a kite out of sticks, discarded plastic bags and twine, and like any boy in any neighborhood in the world, creates a way to play. Another builds a car out of an empty bottle, with stick axles and bottlecap wheels. And a man, with not a cent to his name, finds enough to build a skeleton of a shelter out of sticks and a tarp, and creates a home for his now-homeless famiy. Creative, innovative human beings. Living. Surviving.

You will observe men sitting together on street corners, chatting and watching the world pass by. Others sitting in the outdoor market, selling their wares. Others carrying large sacks of whoknowswhat on their heads as they wander to distant destinations. Women walk past in beautiful, feminine, swaying form, miraculously sleek and clean despite the lack of running water or electricity. They chat and laugh as they pass by in small groups, arm in arm. Flirting. Smiling. Just people. Beautiful people.

And the first intimidating impressions of the slum fade away, and a rich, bustling, intertwined community is revealed.

Yes, there are those that call out angrily and unwelcomingly -- like any small town wary of outsiders. Men who purse their lips in a sexual yet fishlike smacking sound -- a crude invitation to who-knows-what as we pass by. (Uh, let me think that proposal over for a millisecond...ok, that would be a no. Thanks. But, no thanks.) A woman who grabs her crotch angrily, staring boldly as she yells something my internal language translator processes as "danger...unwelcome..." with a few epithets thrown in for good measure. Young children who yell, "Blanc, blanc..." White person. Not out of racist hatred, but more as a matter of you might yell, "Zebra!... Zebra!" if you were to unexpectedly spot one wandering through your neighborhood one sweltering afternoon.

I sometimes wonder what these people, particularly children, will remember of this strange spring that is post-earthquake Port au Prince. Will they sit as young men on a stoop in the 'hood ten years from now, reminiscing about the earthquake of 2010, comparing their fading scars. Will one say, "Damn, do you remember that crazy white guy who used to dangle off the top of that white truck....the one that used to drive by and bandage people?" Ten years from now, will some of them finally have electricity, and have the opportunity to watch a film with Angelina Jolie? Will they suddenly jolt and get the joke, saying, "Wait a minute. Angelina Jolie?! Didn't she used to tend our wounds?!"

We came to this City of the Sun at the request of one of its residents. When the earthquake hit Haiti in January, the orphans at the Heartline Orphanage were all adopted out on Humanitarian Parole. And immediately Hearline Ministries turned its attention to the urgent need for medical relief. One of the men who guarded the orphanage -- a respected leader from the slums of Cite Soleil -- approached the head of the Ministry and requested help. He told stories of many severely injured people in Cite Soleil, and no one willing to enter to provide them assistance or medical care.

So, Heartline took its truck, and its medical volunteers, and drove into the heart of the slums. At the request of this one man. And these American volunteers found, lying on the concrete, a collection of severely injured patients. Pregnant women with pelvic and femur fractures. Children with open tib-fib fractures. Crush injuries. Traumatic amputations. Massive lacerations. Overwhelming devastation. Truck load by truck load, patients were carried out of the slums, to the old orphanage across town that soon became our Heartline Field Hospital.

As patients were left behind in the streets, unable to fit into the truck, they begged, "Please don't forget me...please come back for me."

And so, they were not forgotten. And so, we came back in our truck, again and again and again. Sometimes to pluck the injured and ill from the street. Sometimes to return them home. And many times to provide continued care. In their neighborhood -- the most impoverished neighborhood in the Western Hemisphere.

Until today.

Dr. Jen, young Alex, midwife Beth and I worked in the back of the medical truck today, performing our final wound care in the streets. And on this day discovered that all of the earthquake injuries normally tended to from the truck had finally healed.

As we performed our last dressing changes, we noticed that, as usual, we were attracting our share of curious attention. Dr. Jen, on her right shoulder, wore her own Sharpie tattoo -- the word "Silver" inside of a bright red heart. A tribute to silver-embedded antibiotic dressings, an effective treatment modality which healed many crush wounds in the the months following the earthquake.

As we worked inside the truck, a young man of about 16 stood on the outside of the mesh metal cage.

"Silver..." he whispered seductively to Dr. Jen, having read her tattoo and apparently mistaking her for something other than an emergency medicine pediatrician. An exotic dancer, perhaps?

"Silver..." he called, a little louder. I snickered in undisguised amusement.

"Yo, Silverrrr..." I grinned mockingly, rolling the final r, gesturing to the young man behind the metal mesh. "I think you have an admirer." At that moment, he was shoving a rolled up piece of blue-lined paper through the mesh, trying to get her attention. He called her precious metal name again.

She ignored him. A complete cold shoulder. Absolutely no interest. Was he devastated? Embarrassed? Deflated? No. He quickly turned his attention to me.

"Angelina..." he called suddenly, in my direction. I, in contrast, was cynically flattered. I chose not to be, in any way, overtly peeved by his insultingly conniving, wishywashy, two-timing, less than monogamous intentions. I was impressed by the bold sixteen-year-old confidence that allowed him to turn his attention to me...despite the fact that I had just witnessed his impassioned, enamoured plea to the woman two feet to my left. He'd remembered my pseudonym-- Angelina Jolie; that scored him a few points. And, yes, perhaps lost a few points for the absence of subtlety and sincerity. But still, his score was in the black.

He raised his eyebrows and smiled sweetly now in my direction, imploringly, impassioned. He again tried to push the rolled up piece of paper through the mesh. This time, in my direction.

I raised a cynical eyebrow in return.

"For me?" I asked, with a smirk. Then, flatly, "I'm honored."

"Angelina...." he whispered. "I love you."

I laughed at him. He shoved the piece of paper further through the mesh, wiggling it slightly, urging me to take it. Finally, I grabbed it, and held it like a contaminated cigarette.

"For me?" I asked, amused. He nodded earnestly, eagerly. I turned to Dr. Jen. "See, now it's mine. Too bad for you."

I unrolled the paper with an air of sarcastic dubiousness, but as I read, I was taken aback. This was no quickly scribbled love note. This was, in fact, a manifesto. Not a spontaneous appeal. Not a childlike whim. No, this was, in that moment, an entrancing literary wonder. A blue inked seduction. Obviously planned for quite some time...with no particular audience in mind. Cleverly entitled, "Cherie..." (translation: "My dear...") to enable it to be shared with no particular woman...or, as in this case, passed around, until some poor sucker finally bit. I imagined this young man sitting intently with a Creole-to-English dictionary, a ball point pen and small notebook on his lap in his darkened cinderblock room in the slums, spending hours carefully penning this note. When had he written this? What had been his plan? How long had he had it, rolled up in his pocket. And, at exactly what point had he said, "I will write a love note in English, and hand it to every English speaking woman I meet, until, at some point, I succeed in my quest."

I read the note and smiled, definitely impressed. "That's great," I said. "That's really great." I attempted to hand the note back.

"No," he said, refusing its return. He gestured for me to keep it. "I love you," he said, in English.

"No," I replied, amused, trying to push it back through the mesh. "You don't love me."

He grinned, refusing to take it. I smiled, still gripping the end of the rolled up note.

"Well, okay," I said, and stuck the paper into my shirt pocket. "Merci. I'll keep this."

I smiled to myself, then turned back to my dressing change. He smiled back, completely insincere in his flirtatious, boyish grin. But sweet. And endearing. And completely non-threatening. An A+ for effort. A hilarious, sweet, amusing memory. Of innocence. And youth. Of boyish courageous charm. And love. And hope. And the wonder that it represents -- that this neighborhood is healing. That thoughts are turning, from sadness and devastation and loss, to flirtatious moments of happiness. Healing.

I suspiciously wonder how many copies of this scroll he carries, and in how many languages. But, for today, on our last day in this slum, it is a symbol for me of something sweet and innocent and kind and beautiful and welcoming that is the people of Cite Soleil. Our people. Our patients. This community of challenged, impoverished yet not poor, strong, driven survivors.

So, here's to all you potential suitors out there. Take note...of how you might effectively court a woman. (Of course, I would recommend you not choose one twice your age...and perhaps not one who speaks only a foreign language. And, if unsuccessful in your bidding, you might wait till the first one leaves before trying to court the second...or at least wait till she's more than two feet away, inside of a cage.)

But, if you're trying get a woman's attention, and get her to pause and take's how it's done.

"Cheri, Darling. You thrilling me. You give me goose bumps. You're driving me crazy. I fall in love you. I'm boun to love you. You really I need. I want to be with you. I want to be you sweet. Call you beautiful. I've a place deep on my heart for you. I think with you everitime you always on my mind baby. When I look at you I see the sun shining on your face. Please don't make me suffer. Im head over heel since I met you."

Yes, Citi Soleil...

City of the Sun...

When I look at you, I see the sun shining on your face.

I'm boun' to love you.

I've a place deep on my heart for you...too.

Wednesday, April 14, 2010

The Depths

Photo by Dr. Jen Halverson

A mother stands on a pile of rubble, peering down into its depths.

This tangle of cinderblock and rebar was once her home. Her children's home.

On January 12, 2010, when the earth shook, it became her children's grave.

She stands on the pile of rubble, for the second time, three months from the first. The first time she stood here, amidst terrorizing aftershocks, she desperately dug for her children, impossibly buried in layers of concrete. Miraculously, she found her toddler Emmanuel, crushed but alive, in the depths of the rubble. Only Emmanuel, face and body bloody and torn. On that day, she acted with stoic determination. She took the injured form of her child and left the bodies of her three remaining children behind in the rubble. No time to grieve. No time to reflect. Only time to act with direct and forceful intention. To keep her remaining child alive. And, so, for three months, she has fought for his life.

You may remember Emmanuel's mother. Two weeks ago, when her son had his last in a series of painful plastic surgeries to reconstruct his face, she stood up in the center of our hospital and sang a chilling accapella Alleluhia, praising God for the gift of her child's life.

Today, she peered down, for the second time, into her family's grave.

She asked us to bring her here. For closure. She did not know what to expect. Would the house be gone? An empty lot, where her life had once been? Or would it be hauntingly unchanged, the moment of her loss frozen in time.

We worried for her. What does a mother do when she encounters such a challenge? Which would leave a more gaping hole in her soul -- an empty space where her house and children had once been, or an untouched pile of rubble with the bodies of her babies still trapped within? Would she stand and stare at the base of the rubble? Would she fall on it and wail? Would she start to claw and dig at it? Or would her soul just melt away?

She quietly climbed the untouched rubble pile, peering down into the hole from which three months ago she had plucked her little Emmanuel and beneath which her other children's bodies lay entombed. Then she wandered away silently, over the rubble, searching intently, she later revealed, for a precious momento -- a sacred book of hymns that she had carried with her throughout her life. She did not find it.

Nor did she see -- or perhaps, she just did not acknowledge -- the small brown arm of a child that was still visible, pinned under a concrete slab, in the depths of the rubble below her feet.


Tonight, as I left the hospital, she sat with her Emmanuel on a small cot in the corner of the courtyard, staring silently into the distance. I placed my hand on her shoulder in comfort. She stared up at me, with a depth of sorrow in her eyes, despite her ever present smile. I leaned down to hug her from behind and gave her a gentle kiss on the cheek. She lifted a hand to hold my cheek to hers for a moment. Such depths of sorrow. Invisible, searing, devastating sorrow. Just below the surface of a smile.

How does she survive?

A boy of seventeen lies on our procedure table. It is three months from his injury. He still requires sedation for painful dressing changes. One leg is missing below the knee. The other missing tissue from painful, poorly healing skingrafts. He is new to our hospital, transferred from another facility. He has been quiet, stoic, perhaps shy. He keeps to himself. He smiles when prompted with a greeting, but the smile rarely reaches his eyes.

Under IV sedation, we change his extensive dressings. His pain is blunted, as are his inhibitions. As the medication wears off, he begins to cry. Are his wounds still so exquisitely painful? Then he begins to sob. He raises his arm to cover his eyes. "I should have just died..." he cries. "Why am I alive..." In the misty consciousness of his sedation, his stoic mask is lifted, and his soul is revealed. He cries. He sobs. It is heartwrenching.

He cries first about his physical torment -- still so equisitely painful, twelve weeks out from his injury. The physical pain jostles his subconscious, and the suppressed, terrifying memories, are resurrected. This normally stoic and silent boy, still sedated, begins to sob uncontrolledly. Tears well as he rolls his head to and fro, crying about the loss of his leg.

"How can I live without my leg. What will I do without my leg?" he cries.

Then his mind wanders to the loss of his family. He was trapped in the rubble of his house for days. Twelve family members died in his home on that day.

"Why did I survive?" he asks, sobbing.

His mind wanders again, this time to his future.

"How will I live without my leg? How will I work without my leg?" He sobs.

Heartwrenching. Loss of self. Loss of identity. Loss of a future.

"I need to help my family. My father has lost his job. He cannot work. My family is homeless. They are living in a tent. They are starving. We have no money for food. How will we survive? How will we survive?" He sobs again.

"I was a student, but my school has collapsed. Now I have nothing. I have no job. I have no school. I have no leg. I have no life. I have no home. I have no future. Why didn't I just die? Why didn't I just die?"

He tires. Tears stream down his face. Is he sedated? Or is he awake? Is he rambling helplessly? Or speaking with direct, absolute, sober certainty?

It is heartbreaking. It is devastating. We long to reassure him. We long to comfort him.

Yet so much of what he has said is sobering, raw, undeniable truth.

This is far too much burden for such a young man. Far too much sorrow for one soul to bear.

And yet the story repeats, again and again. Patient after patient. Behind each face. Behind each tarp, in each tent city. So much sorrow. So much loss. So much suffering and grief. So much buried in the shallow depths.

But just barely.

Friday, April 9, 2010

Keep on Survivin'

Go online and search out Destiny's Child "I'm a Survivor". Hook up your speakers, turn the volume on high, with a whole lot of base, and with apologies to your next door neighbors, rock the house. Then close your eyes and listen to the chorus. And imagine what we saw today...

We were discouraged. We'd lost our physical therapist to a family emergency, and our patients appeared amotivated without his constant encouraging presence. Moods were low. Apathy was setting in. Oppressive heat overwheled our tarp covered courtyard hospital. Little six year old Dina, now in a walking cast from her open tib-fib fracture, refused to put down her crutches and bear weight on it. Afraid. Lillian, 10 year old with an externally fixated femur fracture...crying with each episode of physical therapy, more and more fearful of the pain. 59 year old Leeann, lying stoically in bed 23 hours a day, not exercising her healing leg -- going backwards in progress. Our 76 year old below-the-knee amputee Genine, needing to learn how to walk again, having a difficult time even standing up. 20 year old Amanda, with her paralyzed left arm and shattered left leg, lying sadly and disinterested in her cot, staring blankly off into the distance.

We'd hit a wall.

"We just need to get them MOVING..." one nurse said.

"Maybe we could get them to do physical therapy together..." someone else said.

"It needs to be fun," someone else said.

And so the idea spiraled. It was born from the knowledge of a perhaps little-known fact, outside of our hospital, that our Haitian patients have innate and amazing rhythm. And soul. Every night, they sing and clap and stomp together in song in impromptu mass that goes on sometimes for hours. Rocking the house. Rocking the neighborhood, over the cinderblock walls, beyond the plastic tarp that is our roof.

It was evidenced when we watched the film "Madagascar," projected one night on a white cotton sheet tied up to the cinderblock wall. In this Disney film, dubbed in French, shipwrecked zoo animals land in the wilds of Madagascar with a bunch of lemmings who break out into fabulous song, singing a hip deep base beat, "You got to move it, move it. You got to move it, move it. You got to move it, move it...MOVE IT!!" There was nothing cooler than to watch heads start to bob and hands start to sway to the rhythm as all of the patients started to sing along to the beat.

It became obvious that our patients have rhythm.

"Let's make them exercise to "Move it!"" recommended someone else. We all laughed.

Then someone said, "No, really!"



So, somehow it happened that we pulled out the electric sound system used to project movies on the wall at night. And plugged it into Dr. Jen's computer. A quick search of her ITunes files revealed a great assortment of deep beat, hip, rhythmic dance tunes. Including the song, "You all ready for this???!!" -- normally danced to at NFL halftime shows by cheerleaders in skimpy tops and pompoms.

We walked around to each patient and said, "In a minute, we're going to turn on the music, and you will do your PT."

Some patients were assigned a helper. Amputees were given the task -- stand and balance on your strong leg, and try to squat up and down. Bilateral casted patients -- stand up with your walker and balance, then sit back down. Young Dina, who refuses to walk without her crutches...when the music starts, you will walk on your cast...with one crutch, not two. Young Lilian, who starts to cry at the idea of physical therapy -- you will stand with your crutches and just walk around. Each patient assigned a task. They all looked at us curiously, a little dubiously. A little apathetically. A generalized look that shouted...ok, perhaps whispered, disinterestedly, "Ok, whatever..."

But then, the magic happened.

This was no circus music. No accordion music. No elevator music. No polka or grandma's parlor music. This was raging urban hip hop rhythm with wicked base and deep musical soul. Yes, this music required apologies to the neighbors over the cinderblock walls for its volume. Yes, it perhaps shook a bit of dust off the walls. Yes, it was played like your car stereo when you drive solo, speeding down the highway with the volume and bass cranked, wind screaming through your hair. Because on the count of three, when Renauld our interpretor-turned-DJ hit "PLAY", at two in the boring afternoon at our Haitian Field Hospital, he literally rocked the house.

"YOU ALL READY FOR THIS????" the song called, followed by the deep rhythmic beat of sound. Sound which suddenly dragged patients' eyes open, pulled giant smiles from their lips. Heads began to bob. Feet began to tap. Eyes came afire with life as the sound system blared its rhythm across the courtyard. I helped our 76 year old amputee onto her one leg. Her shoulders started to sway in rhythm. A smile crinkled her aged, wrinkled cheeks. Ten-year-old Lillian, afraid to stand, threw down her crutches and danced with her hips swaying and arms undulating rhythmically, balancing crutchless for the first time. Dina marched to the beat on her casted foot, then began to spin and dance. Amanda lay in her cot, brilliant smile, rhythmically rolling her shoulder to the beat. Song after song, shining smile after smile. Little Emmanuel, three year old boy with the crushed face, stood in the center of the courtyard and danced the freespirited dance of a child. Smiles and rhythm of joy. Old and young. Nurses and patients and translators and visitors. Rocked the house.

Then the last song, "I'm a Survivor," by Destiny's Child, began to play. I paused as I stood in the middle of the courtyard, slowly turning around to see the patients dancing and swaying and squatting and bending and smiling and laughing -- incidental physical therapy amidst the endorphin releasing joy of blaring song. Dancing like they were 16 again... perfect... whole... young.. .strong... in their bedroom secretly in front of their mirror. In a club. At a rock concert. A better day. A freer, more innocent day. Rebelliously blaring the music.... When life was simple and beautiful.

The deep, strong African American female voice pounded forcefully from the speaker in front of me. With each lyric, my eyes glanced off of each patient...their stories of survival...of pain...of endurance...of recovery...of spiritual resilience... flashed repeatedly in my mind. Fabulous. Amazing. Unbelievable.

I'm a survivor...
I'm not gonna give up...
I'm not gonna stop...
I'm gonna work harder...
I'm a survivor...
I'm gonna make it..
I will survive...
Keep on survivin'....
I'm a survivor...
I'm not gonna give up...
I'm not gona stop...
I'm gonna work harder...
I'm a survivor...
I'm gonna make it...
I will survive....
Keep on survivin'...
Keep on survivin'.

Friday, April 2, 2010

Help One

The malingerer. The bane of our existence as practitioners of emergency medicine. The patient who walks into the ER faking an illness for secondary gain -- sometimes for attention, sometimes for narcotics, sometimes for an excuse to be absent from work.

Malingers think they are so clever. Yet their behavior is transparent and predictable. The patient who limps in on one foot and limps out on the other. The one who chats happily in the waiting room, but then moans as the doctor walks in. The physical exam that makes no logical sense, consistent with no known disease process and no pattern of human anatomy. The frustrating, time consuming, irritating, abusers of the medical system. The malingerers.

So, wasn't I surprised when the malinger walked through our gate in the form of a eleven year old boy Ramon. He had been a resident of our hospital for nearly two months, healing from a severe foot wound sustained when he fell from the second story of his house during the earthquake of 12 January. Two weeks ago, declared healed, he was finally discharged home to his neighborhood -- the slums of Pele, from which we had initially plucked him. Pele is a 30 minute drive through the city from our Field Hospital, so it is rather amazing to me that Ramon has magically appeared at our gate several times -- alone, without a guardian. Despite his mere 11 years of age, Ramon demonstrates keen urban street smarts necessary for survival in the slum he calls home. Each time he has appeared, he is welcomed in, greeted by fellow patients who have become his friends, fed dinner, and offered a cot to sleep on. We examine his foot. "Looking great, Ramon!" we say. Each time, we allow him to stay overnight, only to bring him home on our next truck visit to his slum. This might seem uncouth -- to keep a child in a hospital without his guardian's permission -- but in a city in which many families have no phone and no way to be contacted, and in a slum too dangerous to be entering after dark, it is the safest solution for all.

Much to my surprise, on Sunday afternoon, Ramon approached me holding his stomach. "Fe mal..." he moaned, looking ill. An exam revealed a generally tender abdomen, but no fever, no change in vital signs. His severe wincing made me concerned for an early appendicitis. "Poor Ramon," I cooed, as I touched his cheek. "I think you need to rest today and we'll watch you closely."

And as I watched closely throughout the day, I was surprised at what I saw. A boy who giggled and smiled and joked with his bed neighbors, rolling hither and yon on his cot, swinging legs carelessly... but who morphed into a giant, grimacing, writhing form when he saw me approach his bed. "Ohhhhh, fe mallllllll...." He would moan. "oooohhhhhhhh...."

I was on to him.

"Where's the pain, Ramon?" I asked. He gestured all around his abdomen. "Is it here?" I asked touching his belly button. "Oui!" he said..."Yes!" "How about here," I asked, pointing to his hip bone. "Oui!" he said, moaning dramatically. I pointed his ribcage, his left shoulder, his right kneecap. "Ooohhhh, fe malllllllll," he moaned. "It hurrrrts..." "Would you like some dinner?" I asked. "Yes!" he responded quickly -- confirming my suspicions that this was not his appendix -- as with that malady, the appetite is the first thing to go. I performed my favorite malingerer exam -- rolling his hair between my fingers. "Does this hurt?" I asked, touching the insensate hairs of his scalp. "Ohhhh, fe hurrrrrtsss..." he moaned. Liar. Bad liar.

I smiled internally as I stood and spoke in my stern but quiet doctor's voice.

Through a translator, I advised, "I see your stomach hurts you, Ramon. Why don't you eat something and get a good night's sleep. I am very sure it will be better in the morning, in time for you to return with us to Pele. If it's not, I'm afraid we will have to bring you to another hospital, because you will be too sick for us to care for you." He nodded, eyes wide. I patted his head. Within minutes of my walking away, he rolled on his belly, swinging his feet happily, chatting with the 12 year old boy in the cot next to him.

Can you blame him? A young, impoverished,malnourished boy from the slums, seeking three square meals a day, a soft, warm bed, a quiet courtyard, a supportive social network, nighttime singing that rocks the house, and an occasional movie projected on a cotton sheet hanging by the metal gate. Paradise? This has become his safe haven, from his slum, his poverty, and the painful and horrifying memories that are the earthquake. The earthquake that killed one out of every 10 people in his neighborhood. The earthquake that shattered his foot.

The next morning, Ramon walked up to me. "Do we need to take you to the other hospital?" I asked, pushing on his stomach.

"No," he responded. His belly was fine.

So, we loaded Ramon into the truck, and drove the thirty minutes back to his neighborhood. We hopped out and walked down the street and into a back alley. Before us stood a looming, teetering structure that was once a two story building, now leaning treacherously to the left, the front wall missing revealing the small rooms withing.

"That's my house," Ramon declared. My heart sank. Ramon's house. The house that he fell from when the wall to his bedroom shook off and crumpled to the street below. The house that still looms threateningly, like a nightmare; a house that blocks fall from with every minor aftershock.

I remember the command given by the Haitian president last month. "Haitian people, return to your homes. Leave your tent cities. Your houses are safe."


Does anyone come in to these slums? Certainly no engineer. No building inspector. I am sure not the President, who commanded the people to return to their homes. Ten weeks after the earthquake, this treacherous building looms, awaiting the next rumble that will rip down the next wall. A nightmare.

I turn to the malingerer. Now I understand. "You're not living in this building?" I ask, with deep concern.

"No," he replied. He walked past the building, between two narrow walls, into an open area behind the structures. Ramon's mother stood there, outside of a shelter made of a cotton sheet held up with four wooden spears. She greeted us and showed us her home. She was not surprised that we brought her son to her...not surprised nor questioning where he had been the last few days. The floor under the sheet was a makeshift mosaic of crumbled cinderblocks. There was no waterproof tarp to keep out the rains. No pad or blanket to sleep on. Just a cinderblock floor and a cotton roof. She was surrounded by five small children -- hers? Neighbors? Children taken in out of necessity, now orphans? No evidence of food...or cooking supplies.

"Okay, bye Ramon," Alicia our nurse and I said as we patted his head and turned to leave. We met each others' eyes with a knowing look. How do we leave this child here? How is this family surviving? Did we invest two months in his life, his recovery, to dump him here on the streets? With inadequate shelter? With the shell of his former house teetering just meters away? Does he have food? What happens when the rains come? How many other children are squatting this way? Statistics say perhaps one million Haitians are now living in flimsy tent shelters. How do we leave this boy here? How do we leave these people here?

I stare at his cotton house. I recall the rains that pour down every other night now, dumping 2-3 inches of rain an hour. And the rainy season is upon us. I feel helpless.

The motivation of an 11 year old street-wise malingerer, revealed.

We walk slowly back to our truck, Alicia and I. Speechless. Yet, unfortunately not surprised. As one stares out at the hillsides, the story is repeated, tens of thousands of times over.



Today we returned to Ramon's alley...and found him playing with his siblings. We presented him with a three person tent and a sleeping pad -- a donation from a nurse who spent a few days volunteering in our clinic. He stared in awe as we handed him the tent. He touched it hesitantly.

"This is for you and your family," we said. "It's not much...but maybe it will help."

He hugged us tightly. We hugged him back.

We walked away.

One life. One small bandaid. One gigantic hemorrhaging wound that is Haiti.


Mother Theresa said: "If you cannot help everyone, help one."

Thursday, April 1, 2010

Please Help Us Find a Neurosurgeon

I have been asked to post this request to help our field hospital find a neurosurgeon for one of our patients.

Amanda, a 22 year old young woman living at the Heartline Field Hospital in Port au Prince, Haiti, was crushed when her neighbor’s house collapsed into hers in the Haiti earthquake on 12 January 2010. She has multiple injuries, including a severe nerve (brachial plexus) injury which causes her to live in incapacitating pain. There are no specialists in Haiti who can perform this repair. We are seeking help to get Amanda to the United States (or elsewhere) to a neurosurgeon/ brachial plexus specialist, in a last hope effort to resolve this young woman’s incapacitating pain. If you know any orthopedists or neurosurgeons, please share Amanda’s story with them, and see if they know anyone who might be able to help Amanda. We are asking that the surgeon and treating hospital donate their services. If and when a surgical team is identified, we will also need financial donations to pay for Amanda’s medevac to the United States, and her room and board while she is there. Amanda has a passport, which will facilitate her travel out of the country.

Here is Amanda’s story:

On the evening of 12 January 2010, young Amanda was standing in her mother’s kitchen outside of Port au Prince. When the earthquake hit, her neighbor’s house came crashing into hers, trapping Amanda under its crushing weight. Her neighbor – and best friend – was killed instantaneously. Earthquake survivors describe the shaking and grinding of the earth on that day as nightmarishly surreal; many believed the world was coming to an end. In the minutes after the large quake, neighborhoods echoed with thousands of screams – some of pain, others of dispair over injured or dead loved ones. The screaming echoed eerily and incessantly into the dark night, through near and distant neighborhoods; the hellish sound reportedly could be heard for miles. One in every ten people in Port au Prince and the outlying communities was killed in the earthquake that shook for less than one minute.

Amanda’s screams of pain were heard by neighbors, who worked aggressively, despite severe aftershocks, to free her from the concrete and rebar grave that trapped her. When finally rescued, it was clear that her life was in danger. Her left arm and femur were crushed – exquisitely painful, and potentially life threatening open wounds. In the United States, such severe injuries would have gotten Amanda life-flighted to the nearest trauma center for emergency surgery. In Haiti in the week following the earthquake, she was one of more than 100,000 severely injured individuals desperate – and unable – to find care.

Imagine, in that moment, that Amanda is your daughter, your sister, or your friend. And you are desperately trying to find her care. You drive first to your local hospital – which is absolutely overwhelmed. She is there for two days, and receives an IV, but no pain medications and no orthopedic care. She is in agony. You become desperate; you decide to drive her to the city. Certainly there, at one of the big city hospitals, she will receive help. But many of the big hospitals, you soon discover -- to your horror -- have been destroyed. You find one – hospital number two – and take her there. After a day, she again receives no care. So, you drag her unsplinted, broken form in search of a rumored orthopedic field hospital. You cannot find it, so you sleep with her in the streets, cradling her crying form through the night in your arms. In the morning, you take her to hospital number three. No care. You search again for the rumored field hospital and finally move her again – still unsplinted, still without pain medication, to hospital number four. There, she is loaded into a truck and convoyed across the countryside – still without pain medication and still unsplinted, every jolt on the country highway grinding bone on bone – to the Dominican Republic, the country east of Haiti, to hospital number five. There she finally sees an orthopedist, who places a metallic external fixator into the shattered bones of her left femur and a metal rod to stabilize the open fracture of her upper left arm. There they discover that her left arm is paralyzed and burning with severe, intractable nerve pain; the bone is also infected, as her open fracture remained uncleaned for so long. You meet a representative of another field hospital located back in Haiti -- one that has orthopedists and plastic surgeons, and can manage her open wounds and infections. So, you truck young Amanda, once again, over the bumpy rural highway, back to Port au Prince, the city from which you started, to hospital number six -- Merlin Field Hospital. There, in a collection of canvas tents on an old tennis court, European physicians place skin grafts over her open wounds of her leg, and further manage her infection. You discover that they, too, are overwhelmed with patients, and recommend transferring her to hospital number seven – Heartline Field Hospital – for pain and infection management and rehabilitation. At Heartline, it becomes obvious that the nerve pain in her arm is severe and unremitting; so she is transferred temporarily to Miami Field Hospital – hospital number eight -- where an anesthesiologist places a temporary catheter into her chest through which pain medication can be infused to blunt the nerve pain in her now non-functional left arm. This intervention fails. She is transferred back to Heartline for regular care and rehab. Her unremitting pain continues. Orthopedists, plastic surgeons and neurologists agree -- no one in Haiti can fix this girl's injury. Imagine this is your sister, your daughter, your friend. The agony of her journey. The agony of months of intractable pain. The overwhelming hopelessness.

Amanda’s femur is slowly healing, but arm pain remains severe. The unfair irony of Amanda's arm injury -- a probable stretch or tear of the brachial plexus -- is that although the nerves to her arm now fail to function, and it hangs limp and unusable at her side, she is plagued not with arm numbness, but with severe, incessant pain. Nerve pain. Imagine the worst ice cream headache of your life. Or the worst sciatica of your life. Imagine the pain you get when the dentist pokes his metal hook right into that sensitive part of your tooth. Fiery, electrical, intolerable pain. That is nerve pain. Now, imagine living with it, with no hope for relief. This is Amanda’s burden.

Some have recommended amputation of Amanda's left arm. The problem is, the nerve bundle lies above her shoulder, so amputation would disfigure her without alleviating the intractable pain. Even with her left arm gone, she would still suffer severe phantom pain, which she would feel travelling from her shoulder to the fingertips of her now missing limb.

There is a possible surgical intervention for Amanda -- brachial plexus repair. But there is no one in Haiti able to perform it. There are a few specialists in the United States who can. But the clock is ticking. The farther she gets from her injury, the less likely it can be successfully repaired. And the more likely this young 20 year old woman will live with devastating pain. As one orthopedist bluntly put it, "This injury will not kill her. But suicide, from the ongoing, unremitting pain, could."

Please help Amanda. We need to find her a surgeon. And we need the funding to get her to the United States, and support her while she is there.

If you can help in any way – be it a donation, an offer of housing or transportation, or a medical contact, please contact Heartline Ministries at Together, we believe the Heartline Field Hospital community and contacts can come together to find Amanda a final solution – at hospital number nine. We will keep you informed of our progress to find Amanda care.
Please forward this request on to anyone you feel might help with Amanda’s case.

Heartline Field Hospital, Heartline Ministries, Port au Prince, Haiti

Monday, March 29, 2010


This child is starving.

He presented to our clinic at 10pm two nights ago, a floppy, dehydrated, malnourished skeleton of a boy. Carried in by an apathetic, apparently disinterested mother. Is she disenchanted with her lethargic child? Uncaring? Exhausted? Cruel? Unkind? Or just overwhelmed, and disengaged? Filled with her own stressers and poverty too overwhelming to communicate, so she instead stares blankly across the room with an air of dispirited disinterest? He whimpers as his head flops backward, his neck too weak to lift it. She ignores him. She does not watch him, hold him, soothe him, make any eye contact. He lies in her arms like a wet, unloved rag doll. He appears to be an irritant. But, yet, she walked in with him, sought help for him, at 10 o'clock at night. He has not eaten a thing in 14 days, per mom. How is it possible he is still alive? What inspired her to finally come, on the 14th day?


A young girl is carried on her brother's back to our truck in the slums. She is 12 years old, sweating and semi-conscious. She was standing in a food line in the blazing noon heat, and slumped to the ground, unconscious. We lay her on the floor of our truck. Likely dehydrated and hypoglycemic. I take honey that we carry for wound care and rub a thick layer into the mucous membranes inside of her cheeks and gums. She gradually returns to full consciousness. We feed her granola bars we carry for ourselves, and sips of water, until she revives. I explain that she needs to go home and rest out of the sun, and eat something.

"Do you have any food at home?" I ask, realizing that she had been standing in a food line when this all began.

"No," her brother responds for her, meeting my eyes solemnly. "We have nothing."

"No," she mirrors, shakily, and starts to sob hopelessly. "We have nothing. Nothing..."


Have you ever met a truly starving human being? They surround us.

Sunday, March 28, 2010


A mother stands in the center of our tent hospital. Her toddler stands at her feet, hiding his face in the folds of her skirt at her legs; he tugs repeatedly at her dress to get her attention. When he fails, he -- in typical two year old fashion -- cries out in frustration, tugging harder, grunting, trying to climb her. This draws knowing smiles and giggles from the patients and our staff. Headstrong, willful, smiley Emmanuel. Always trying to get his way.

If you look closer at the belligerent child, you will notice scars along his scalp, winding through the tangled mass of his dark hair. As you follow them, they will draw you to his face, where they course across his right eye, and down the side of his nose. These thick jagged lines are complimented by the more precise and straight surgical scars which track down his forehead, behind his ear and along the side of his neck. Emmanuel's face hints at a horrific story.

He has been passed from surgical team to surgical team -- first on the USS Comfort, then the Merlin surgical tents set up on an old tennis court, and finally, yesterday, Miami's white tent hospital at the airport. He has been our inpatient in between. We had been searching for a surgeon to make a final revision to Emmanuel's scars, but for weeks, no one could do this, due to lack of an anesthesiologist to properly control his airway for the final complicated surgical intervention. So, for weeks, Emmanuel has stayed in our tent hospital, with his dramatically deformed face, a prosthetic device sutured into his nostrils to prevent them from scarring shut, and a flap of tissue from his forehead twisted at its base to cover the place that once was his nose. Though the right side of his face was mangled, the left eye was largely unharmed, and it is through this left eye, and his intact smile, that Emmanuel has won the hearts of our hospital crew.

While rounding on patients, it is not uncommon to feel a sudden sharp slap on one's back side, and to spin around indignantly to find Emmanuel grinning, his left eye crinkled into a smile, his hand still raised in a gleeful threat that he is about to slap you in the butt once again. If you hold out a fist to him, he pulls out his, and gives a powerful fist bump greeting -- a sign that he is, indeed, a little Haitian man. He will sneak up upon you to unzip your pants pockets and steal your pens. And is commonly seen proudly wandering with a bag of drinking water that he has cleverly pilfered from a controlled stash at the nurse's station.

Two days ago, on a scouting visit to the Miami Field Hospital -- which has, by the way, received the official word from the government that it must move off of the Airport property in 3 weeks -- I wandered my way through the pediatric tent, and into the back surgical suite, bearing a photograph of Emmanuel's face on my telephone. I approached a group of men and women in surgical garb. Understand that, in the USA, a perfect stranger wandering in sandaled feet, a t-shirt and khaki pants into a surgical suite would guarantee one an escort out to the street in handcuffs by a thug in a dark security outfit. But there, with my American looking face and a strategically placed stethoscope, I received only curious stares from the surgical staff.

"Hey," I asked, with pseudo-casualness. "Is anyone here a plastic surgeon?"

And, unbelievably, as if I were standing inside a poorly written Hollywood movie, a handsome man in blue scrubs with a surgical mask dangling around his neck looked up and said, "I am a plastic surgeon. How can I help you?"

Really?? I asked myself internally. Did that just happen? Perhaps you don't quite understand....the number of virtual roadblocks and cement walls and alligator-filled moats we have transcended trying to achieve this very encounter, this moment in time. And here, finally, it was presenting itself. So shockingly simply.

"Uh.. great," I said, trying to appear casually unimpressed by this moment of good fortune. I turned on on my phone and opened to the photo of Emmanuel, turning it towards him. "Can you help this boy?"

The surgeon took my phone and stared at it. "Looks like he's had a half finished flap procedure..." he said, naming off specific flaps and techniques standard in his surgical world. I explained that we'd been unable to find an anesthesiologist, and were therefore unable to complete the revision...that we (and Emmanuel) were stuck, half finished, without a plan for his next essential plastic surgical intervention. We didn't know how to proceed.

"Okay," he said. "I'll do him tomorrow."

My mind stuttered with momentary incredulity. day after today tomorrow? Unbelievable. Outwardly, I nodded, with an false air of calm professionalism. Inwardly, I laughed -- a laugh of deep, fatigued relief.

Thank. God.

So, already overwhelmed, you can only imagine my reaction when he also agreed to do surgery on Rony, our other boy with facial trauma -- the one who'd had Bot fly larvae growing in his eye socket, and for whom we'd also been searching desperately for a surgeon.

I merely scrolled to Rony's picture on my phone, and thrust the photo at him, breathlessly challenging, "Okay, well, while we're at it... what about him?"

After he inspected the picture, and heard Rony's story, he said, "Okay, I'm leaving in a couple of days, but I'll fit them both into my schedule. Bring them both back this afternoon."

This afternoon.

I stared blankly for a moment, then a smile cracked my face. Unbelievable.

"This afternoon," I repeated to him, then nodded. "We'll be here." I retreated backwards through the door of the surgical suite, with a forced casual wave of my hand...then turned, and with a great lack of professionalism, sprinted back to the truck, intending to retrieve the boys before this vortex of luck stopped spinning.

And so today, two days later, Emmanuel and Rony reappeared back at the gate of our hospital, accompanied by our nurse, surgery complete. For the sake of their privacy, I will not include their photos here, but rest assured that the results were absolutely stunning-- as evidenced by Emmanuel's mother, who beamed a gigantic smile as she carried her boy proudly back through the metal gate into the courtyard of our field hospital.

Emmanuel's transformed appearance raised audible gasps -- which, ironically, it did not do when he had previously presented his disfigured face to the world. But now, with the fine scars of a deft surgical hand tracking down his face, where there once was a tangle of tissue, was the beautiful, nearly symmetrical face of a child.

So, today, beaming mother stood up in the courtyard of the tent hospital, little Emmanuel squirming at her feet, and told our community she had something to say. She closed her eyes, and began to sing, a deep, resonant rendition of a Creole hymn, "Alleluia..." All the patients fell silent as she sang, her little toddler at her feet trying unsuccessfully to climb up her dress. She swayed and raised her hands in song, thanking her God for healing her child.

Her gratitude is impressive, particularly if you know the rest of her story. This woman, who stood up to sing her thanks for all she has received, had three other children. But they are now dead. They were all crushed -- and are still buried -- in the rubble that was her house, which collapsed in the earthquake of 12 January 2010. The house under which her little Emmanuel was trapped, then plucked free. Her shattered little boy, all that remains of her family.

Emmanuel. Beautiful, vigorous, little spirit. Miracle boy. His mother's last hope.

Made whole a stranger in blue scrubs...who made the time.


Friday, March 26, 2010

Faux Pie

How can this be?

It is ten weeks from the earthquake, and today, as we performed wound care on our truck in the slum of Pele, two men walked towards us up the street carrying a middle aged woman on a folding metal chair. I did not recognize her. Neither did Alex. Her right leg was wrapped in a makeshift splint, now dirty from weeks of wear. Her left leg was missing below the knee. I climbed out of the truck to greet them.

"Hello," I said. "How are you?"

"Please help us," implored the older man as he set the woman down on the street beside the truck. He identified himself as her husband.

"Of course," I replied. "Tell me about your injuries..."

"She received care in a hospital in the Dominican Republic in the days after the earthquake," he replied. "They cut off her leg, and put the other in a splint."

"Where is your leg broken?" I asked, pointing to the mass of gauze and plaster. Followed by our commonly asked, but clinically unusual question: "Did you have an x-ray?"

"I don't know where it's broken," she replied to the first question. "No," to the second question. "No x-ray."

We have seen this situation repeatedly. A patient in a splint for a non-specific, unidentified fracture. In the chaos of the post earthquake situation, probable fractures were splinted based on symptoms -- appropriately so in the critical triage environment. We found one poor elderly gentleman placed for eight weeks in an uncomfortable long leg cast -- only to x-ray him to discover he'd never broken his leg to begin with. So, once again, another patient with an unknown fracture. But, ten weeks out, one would expect the bones to be healed.

I cut off the splint and took her leg into my hands. With a torquing twist to the lower leg, I felt the bones grind harshly against each other -- a malunion (unhealed fracture), so unexpected this long from the injury.

"You've been unable to walk on this, because of pain, I'll bet," I said.

"Walk?" she asked incredulously, almost accusingly. As if to say, "How do you think I will every walk again."

"Do you have crutches?" I continued.

"No," her husband replied. "We just carry her around in this chair." He pointed to a folding, slightly rusted metal office chair.

I squatted down beside her to meet her eye. Her situation was becoming clear. A woman with an aggressive post-earthquake amputation and a shattered surviving leg. Sent back to the streets -- to a tarp shelter? -- just days after her surgery. Unable to walk. Given no instructions. No rehabilitation. Provided no crutches. Nor a plan of follow-up. Now assuming she will be non-amblatory for the remainder of her life -- crippled. And a constant burden on her family.

"You know," I told her, resting my hand on the leg above her splint. "We have a patient just like you in our hospital. She had both of her legs crushed under a wall. She had one leg amputated and the other severely broken. Just like you."

The woman nodded.

"She took her first steps this week, at our hospital, using crutches," I told her with a smile. "Would you like to walk again, too?"

The woman and her husband both looked at me with astonishment. As if they had never imagined this could be an option. Her son, who had carried the other side of her chair, grabbed my arm.

"Please," he asked with urgency. "We want to fix her legs. Please...can you fix her legs?"

"How about this," I said. "Get on our truck with us, and come back to our hospital. You can stay with us for a while. We'll get an x-ray of your leg, to know how it's healing. We'll give you physical therapy to help you get stronger. And we'll give you crutches, so that we can teach you how to walk again. And I will connect you with a we can find you a new leg."

"A faux pie?" her son asked with excitement. A fake leg?

"Yes," I said. "A faux pie. Will you come with us?"

The woman nodded quietly, a look of hope in her eyes. Her husband's eyes filled with tears. They gripped each others' hands.

Where had these people come from, ten weeks after the earthquake. From which make-shift shelter down which little alley in this labarynth of cinderblock shelters and tarps? Where had they been these past 10 weeks? How had they found out about our truck? And why had we not met them sooner? How many other patients are lying in the slums of Port au Prince, hopeless, helpless, crippled...completely unable to access care? Being tended to on the floors of their homes, or carried around by their families? How many more are out there

We carried the woman in her chair into the back of the truck. Inside, I asked her her story. With the typical flat, matter of fact affect that is so common amongst our patients -- a protective mechanism, I assume, to limit the power of the torturous memory -- she described that she was a restaurant owner, and the wall of her business collapsed upon her during the earthquake, pinning her for five days under the rubble. Five days of agony, leading ultimately to amputation and severe disability.

We drove this woman, along with two other patients with poorly healing fractures, to a volunteer medical organization called Merlin late in the afternoon. Merlin arrived in Port au Prince within the first weeks of the earthquake, providing volunteer orthopedists and plastic surgeons. They operate out of green canvas tents set up on an old tennis court in the center of the city. There, I met with Mister Andrew, a retired orthopedic surgeon from England. "Mister", he had educated me, is the title for surgeons in England, not "Doctor". He is, like so many here, something of a character; a gangly old chap with thinning grey hair, glasses falling down to the tip of his nose, a giant floppy safari hat to protect his pale British skin from the blazing Haitian heat, and occasionally seen wandering through the tents with a fragile china tea cup with a saucer. A brilliant mind, with a golden heart. The days of long hours wear on his face.

I shook his hand and sheepishly began, "I know it's late, Mister Andrew, but we've found three patients on the street today who need x-rays." The doctors at Merlin have a curfew, and are forced to be out of their tents and back to secure housing by sundown due to safety concerns; at night, the tents and patients are watched over by local Haitian staff and security guards. As I spoke, the sky was turning a pale orange, as the sun threatened to drop below the horizon.

"Bring them in," he said, without a blink of an eye.

I described each patient's scenario. Under the fluoroscopy of his mobile C-arm x-ray, each fracture revealed itself to be a shattered mess, non-healing despite 10 weeks in splints.

"I'm leaving in three days," he said, "and we have no plan for replacing me as an orthopedist."

My heart sank. What will we do, without an orthopod in the coming weeks?

"All of these patients need surgery," he continued.

"Okay," I said hesitantly, "What shall we do?"

"Well, you'll leave them all with me, and I'll fix them all before I go."

Perhaps you don't know how generous and selfless this man's offer was. A man old enough, and currently appearing tired enough, to be your grandpa. Operating in a stuffy canvas tent under the blazing Haitian sun. With years of practical experience, doing orthopedics long before the fancy modern technologies we now enjoy. An offer beyond generosity.

"It won't be easy, though. Ten weeks from the injury...with some calcification setting won't be easy," he said, shaking is head.

"Wow, thanks," I said. "I'm so grateful. We'll take them back from you right after surgery." Then, "If we didn't do the surgery," I asked, as I looked at his tired face. "What would happen?"

He laughed, shaking his head, "Well," he pondered. "I imagine nobody knows. I've never left fractures like this to heal on their own. You just don't do it. This is unprecedented. I wouldn't be the one doing a clinical trial, leaving these people without surgery to see how they fare. It's just unprescendented."

So, we left our patients, including our lady and her metal chair, with Mister Andrew, the grandfatherly safari-bound orthopod from Britain. She couldn't be in better, caring, experienced hands.

And when he is finished, we will take her back to our hospital, tend to her incisions, give her crutches, and teach her to walk again. And find her her a cherished "faux pie". So that she can reenter society, standing tall like the woman she once was.

How many more of these patients are out there in the city, unhealed after ten weeks of suffering?

What will we do when the orthopedists go away?

This crisis is no where near resolved.

Thank you, Mister Andrew, for your amazing generosity of time, knowledge and compassion.

Did I mention that, with each patient, he pulls out a colorful hand made spiral "lolly" from a candystore back from his home town in England, that he carried to Haiti on his back with his medical tools? "Who was a good girl today," he smiles as he leans over and hands one to our woman.

She takes it hesitantly, and her guarded eyes open, and she smiles at his grandfatherly form.

"Well, allrighty," he says, then turns and shakes my hand. He meets my eyes over the glasses that fall to the tip of his nose. "Thank you for what you do," he says with great seriousness.

"Are you kidding?" I reply. "No, Mr. Andrew. Thank YOU."

Monday, March 22, 2010

I Have One Word for You: Plastic

I must get this off of my mind.

There is a wall of garbage in the streams and waterways of the slums of Port au Prince, which floats up after large rainstorms and spills out onto the streets and walkways. This garbage is largely plastic bottles and Styrofoam. I'm not talking a few bottles. Or a few Styrofoam plates. I'm talking thousands and thousands and thousands.

If you ever wondered what happens to that plastic bottle from your springwater, or the Styrofoam container from your takeout dinner, please remember these photographs. The bottles disposed of in these Port au Prince waterways gradually wash out to sea. In the center of the Pacific ocean, there is now apparently an area twice the size of Texas which, due to overlapping ocean currents, traps a floating island of waste. This waste circulates, gradually disintegrates, and forms plasticized sand and particles, now fed upon by marine animals, and disrupting the nutrition of wildlife. In containers that fail to wash away, in the neighborhoods of Port au Prince, small pools of stagnant water are trapped-- each becoming a small, floating incubator in which the mosquitoes carrying Dengue "Breakbone" fever lay their numerous larvae. For a thousand reasons -- aesthetic, environmental, biological, and humanitarian -- this litter has devastating consequences.
There is no plastic recycling in Haiti. Apparently, the President of the country is aware of this extreme plastic trash disposal problem -- so severe that he actually refused the delivery of relief drinking water in plastic bottles in the days after the earthquake.

I would like to propose an idea...but have no idea how to implement it. Perhaps one of you readers might have some idea how to go forth. If a recycled plastic bottle is worth 5 cents American, one could make a massive profit by collecting hundreds of thousands of plastic bottles. Consider paying Haitians a penny per plastic bottle they collect. If the average Haitian makes approximately two American dollars per day of hard labor, it is very likely he or she would be willing to make the same by collecting 200 plastic bottles. Reimburse them a dollar for each hundred bottles. Then take the bottles and recycle them. Grind them up, melt them down, and turn them into plastic tarps. Or turn them into plasticized, wood-like building products -- flexible enough to withstand hurricane force winds and the tremors of earthquakes; such materials are used to make public benches and decks, as visible in American National Parks. There are may ways to recycle and reuse these products. And to do so would get the garbage off the streets and out of the waterways. And possibly provide an income and an industry for the people of Haiti.

Anybody know how to pursue this dream? A win-win-win situation for Haiti?

Anyone interested in starting a plastic recycling center?

Friday, March 19, 2010

Coming Back to Life

This week's good moments...

The kids out in the slum of Pele are still calling me Angelina Jolie. This is my fault. In a weak moment, while doing wound care last week, unable to stand one more poke to my back by little fingers through the metal mesh wall of the truck accompanied by the stereo "heybarbieheybarbiebarbiebarbieheybarbieIloveyoubarbiegivemewaterbarbie", I turned around and declared in a pseudo-huff, "My name is not Barbie. It's Angelina Jolie!" Little did I realize, they were paying such attention. Now, days later, as I am poked, I can do nothing but smile with bemusement. "AngelinaAngelinaIloveyougivemewaterAngelina..." My own little Pele paparrazi.

Dr. Jenn, our fabulous pediatrician, came out with us on the truck, and now the kids are calling her Jennifer Lopez. Hmmmm....I wonder how that happenned.

A little boy of about 8 years old flashed me an obscene finger gesture as he stared at me through the bars on the truck. "No," I yelled at him, flashing back the peace sign. "La pe! La pe!" (Peace. Peace.) He looked taken aback for a moment, then lifted his index finger to join his middle finger. "La pe..?" he said tentatively to me. "La pe!" I gestured back, encouragingly, fingers raised in the universally recognized vee of peace. Suddenly a smile lit up his face, and he waved his peace sign vigorously shouting, "La pe!! La pe!" His buddies quickly followed suit. If only all peace talks were so simple.

Riding around the city on the top of the truck in a refreshing warm rain, pedestrians called out mockingly, "Hey you, you're getting wet!" "Yeah," we called back, " So are you."

Antoinette, with the most perfect, fragile, angelic face and soft, musical voice. Crushed under a wall inside of her house while pregnant, with one leg amputated and another crushed, was told this week we could remove the metal external fixator holding together her shattered tibia. And that she is now allowed to walk. She is our last patient finally cleared to walk. When told, she immediately stared off into space, rocking back and forth and chanting something repetitive. Concerned she was fearing the upcoming procedure, I asked our translator what she was saying. "She's saying, 'Thank you God, thank you God...' he said, matter of factly. Lying in the caring arms of Dr. Jenn, with eyes closed, softly singing, the stabilizing metal rods were one by one removed.

Baby Kenny, the three pound near-death septic baby, for whom we artificially breathed every three seconds in the back seat of our truck on my first day in Haiti...fighting for his life...whose mother wailed in fear of his imminent now back in our care. And through the patient education of Beth our midwife, is now breastfed by his teenage mother. And this week, hit a whopping five pounds.

Patrick, a 13 year old boy who presented to our clinic a few days after the earthquake with his tibia bone broken and jutting out through his skin, will get his metal external fixator device off next week as well. He's had a long, challenging course, complicated by recurrent infection and skin grafting. A young man with great grit and courage. He currently walks around with crutches that he's decorated with small sayings in English written in Sharpie pen. My favorite is a spelling error, where he mistook an "n" for an "m". It reads, "I BELIEVE IM GOD"

Rony, 11 year old boy with a crushed, scarred right face and bot fly larvae removed from his eye orbit, who wandered the street for 6 weeks without care before finding treatment, picked up a pen today. And drew a self portrait. Of a beautiful symmetrical boy.

I was gifted t-shirt this week. In big white letters on dark blue cotton it reads "MALARIA SUCKS." Indeed.

We tracked down "goat poop girl", who'd shunned our western medical method for treatment of a large hand burn -- scraping off our silvadine burn cream and replacing it the next day with a thick layer of brown goat poop. Her hand looked great. So much for my anti-fecal medical practices.

Jameson, a young boy we found in the slum of Twa Bebe, near the plastic bottle and pig filled river, went home this week. We'd found him in a bright green, dirty cast extending from his abdomen to his foot -- treatment for an unstable femur fracture. He'd been released to the streets with no follow-up...destined to outgrow his restrictive green prison. We were able to scoop him up, get follow-up orthopedic care, ultimately remove his cast, and provide him with physical therapy. A beautiful moment, as he walked with us down the cement path to his home, assisted by his crutches. He paused at the door to his single room cinder block home and a woman came out -- his mother. She cradled his face gently in her hands, staring into his eyes. And kissed him on the forehead as tears welled in her eyes. She then folded her hands across her heart, turned to look at us, and bowed her head, saying "Merci...merci...." Jameson, in typical preteen boy fashion, shrugged away his mom's attention with a grimace, and wandered over to sit on the stoop -- apparently his favorite spot. The spot from which we'd plucked him.

Coming back to life.

Yeah, it's been a good week.

Thursday, March 18, 2010

2:00am, Miami Field Hospital: Take two

Been a bit crazy these past few days and haven't had much time to breathe, let alone write. But I did want to pass on a few thanks...

Thanks to those of you who wrote to say they are contacting their political representatives to encourage better management/utilization of disaster aid resources here in Haiti. Continually bringing attention back to this disaster is one powerful way to promote change. If you are fortunate to have a political voice, those who don't will benefit from yours.

I, ironically, don't have a voice today. Lost it to laryngitis a night ago. Is this some sort of cosmic metaphor?

Perhaps it was all the screaming in the car. I learned that it's not a good idea for a dog to be sleeping in a little dog-circle in the middle of the road at 2:00am when Beth, our midwife, is driving a laboring mom requiring a stat c-section across Port au Prince in search of a surgeon...after the OB/Gyn at the local Haitian hospital came out to say, "I would do the c-section now, as the baby is dying, but we only have one OR and it's currently being used."

We'd looked at each other in that moment and said, "Miami Field Hospital."

Of course, you know the history of us and Miami Field Hospital at 2:00am. So, you can understand why those words were followed by words such as, "@!#$)!" (My word.) And, "Let's go, let's go!" And, "This time, we're going to just drive right thought that gate, whether it's open or not." Oh, yes, and "Get out of the way, you damned dog!!!"

Perhaps it was partially the actions of all of you readers, but this time, when I jumped out of the car at Miami's locked wooden gate, a number of hair-raising minutes later, screaming "Emergency!! Emergency!!" in the dark of the 2:00 night, the guard appeared and immediately opened the belligerance, no flashing of guns, no political negotiations, no need for Beth to pull the old Duke's of Hazard power-over-the-fence stunt. Just an unquestioning swinging open of the gate. (Wow.)

Within minutes, our patient was in the hands of an OB/GYN surgeon, who immediately took momma into surgery, and delivered a healthy baby boy. Initial APGARS were 4. If you are familiar with that scale, you know that that means baby likely didn't have a lot longer in his mom's belly before this story would have had a very tragic ending.

In return for their surgical support, the Miami Hopital team traded us two actively laboring patients.

"If you can take these ladies off of our hands, we'll do your c-section."

Quite the trade. Beth didn't blink an eye.

Thank God for coffee. And beautiful, talented, don't-take-no-for-an-answer midwives. And volunteer surgeons. And readers who take political action...

Because of you, there are three new healthy Haitian babies in the world today.

Keep these babies in your thoughts. Because they are part of the future of this nation. And they'll need your continued attention and advocacy to have a better life.

Oh, yeah, and the dog...he's okay, too. Probably because midwife Beth learned how to drive in Boston.

The other Boston.

Monday, March 15, 2010


Let me explain to you the anger surging through me as I sit in the back of our pickup truck at 2:00 AM with the limp form of a child draped over my legs.

Travel back with me to 1:15AM. the gentle, hesitant high pitch of a child. In the distant corner of the courtyard of our hospital, under a tarp. She is trying to be quiet. She knows it is dark in the hospital, and people around her are trying to sleep. Mewing like a small, injured kitten. Tears run down her cheeks. Her legs are pulled to her abdomen. Heat rises off her febrile form, burning. Her lower jaw trembles as a wave of rigors shakes her small body. Blistering fever.

Father looks on with quiet, concerned eyes. He stands above her and watches intently as I examine her in the small circle of light of my headlamp, kneeling beside her cot in the darkness. Her heart is racing. Heat radiates off of her body. I gently touch her abdomen. A small whimper escapes her dry lips and her glassy eyes open to meet mine. Her hand touches mine and attempts to push it away. "Fe mal..." she whispers weakly. "Fe mal..." It hurts. I hold her small, protesting hand in my left, and push again gently with my right. Her eyes clench tightly. She sucks in a deep breath and whimpers again. Her belly is rigid. A frighteningly sick child.

"This is very bad..." I whisper to our nurse translator as I administer a dose of morphine. "We need to get her to a"

She had presented to our hospital earlier in the afternoon with high fever, headache and abdominal pain. We tested her for malaria -- which will become epidemic as the rainy season encroaches and the mosquito vectors reproduce in pools of standing water. She was, unfortunately, negative. "Unfortunately", because in Haiti, malaria is a very serious, but very drug sensitive illness which is relatively easily treated when diagnosed. With the easy diagnosis eliminated, the more concerning reared their ugly heads. Typhoid? A severe intestinal illness leading to bloody diarrhea, severe abdominal pain and sometimes intestinal rupture. Early appendicitis? Both requiring a surgeon.

Our pediatrician, earlier in the day, drove with the girl to Miami Field Hospital to consult one of the volunteer American pediatric surgeons. The surgeon evaluated her, and advised that her illness was early, and nonspecific, and that we should watch her carefully, treating for possible infection. This is a common medical practice, even in the United States -- watch the patient closely, and await for the illness to "declare itself" into a specific diagnosis. If it declares, come back immediately.

So, at 1:15AM, the illness declared. Quite vigorously. And absolutely. Intestinal perforation. Millions of small bacteria from the intestines spilling violently into the pristine, sterile cavity of the small child's abdomen. An exquisitely painful and potentially deadly event.

We called our midwife, who lives one street over, and has a truck, begging a ride back to the Miami Field Hospital. Father carried his precious child to the back of the pickup and lay her gently across my lap. And in the darkness of early morning, we drove through the deserted streets of Port au Prince, to the only available surgeon in the city. The heat of her body burned across mine, small moans escaping her lips.

The Miami Field Hospital is located in a series of large tents inside the walls of the Port au Prince airport. It was set up within the days after the 12 January earthquake, and placed to be central and convenient to patients, international volunteer medical providers, and imported medical resources/equipment. From outside, it is a series of giant white tents; inside, a bustling field hospital with a lab, pharmacy, xray, and adult, pediatric and neonatal ICU. It is our -- and much of Haiti's -- only referral center for patients requiring intensive emergency and surgical care, as much of the city's medical infrastructure was destroyed in the quake, and many medical professionals were killed. At present is the last hope of many of Haiti's sickest patients.

At 2am, we arrived at a new entrance to the hospital -- a set of wooden gates recently placed into the concrete wall surrounding the airport. This new, unadvertised, unmarked and solitary entrance to the Miami Field Hospital was luckily discovered by our clinic staff during the visit to the hospital the previous day.

Our American midwife, 20 year resident of Haiti, pulled the pickup truck in front of the gates and sounded her horn repeatedly. The gate was locked tight.

"How can the gates be locked?" I asked. "This is crazy."

She honked the horn again and again, echoing in the early morning darkness. Finally, from behind the gate meandered a man in dark clothing appearing to carry a weapon. A security guard. She honked her horn again. The man did not move.

Our midwife turned to our Haitian translator. "Go tell him to open the gate. Tell him we have a sick child in the truck, and this is a medical emergency."

Our translator exited the truck, running to speak to the man behind the gate. Words were exchanged vigorously back and forth. Finally, he turned and ran back to us.

"He says the hospital has closed, and the doctors have all gone."

I am stunned.

"What? No it's not..." I declare with frustration and disbelief. "No, they haven't left. That's not true. That's crazy!"

Our midwife shares my incredulity. This is obviously a mistake. Just 5 hours ago, the child on my lap was in this very tent hospital, consulting with a pediatric surgeon from USC Los Angeles. A hospital overflowing with patients, volunteer medical staff, and technical medical resources. There is absolutely no way this hospital has closed its doors and evacuated it's staff in the 5 hours since our previous visit.

Our translator turns to our midwife. "You're going to have to show your face," he declares with a mixture of frustration and acceptance.

Translation: You need to show your caucasian, non-Haitian face. You need to play the White Card.

Our midwife-- fabulous, strong, intelligent, compassionate, wielding a beautiful Boston accent (the other Boston) -- gets forcefully out of the car. She strides powerfully and authoritatively to the gate, and in fluent Creole, confronts the guard.

She advocates. This is a medical emergency. There is a dying child in the car. She was at the hospital earlier in the day. The head surgeon saw her. He asked that she return. We are an ambulance from a Field Hospital. LET US THROUGH THAT GATE.

"No," says the guard. "The hospital is closed."

I can see the top of the hospital tent over the wall surrounding the airport. It is illuminated white against the 2am night sky. It is obviously inhabited and operational.

I am growing furious. I am growing desperate. This is obviously a political power play. And we are the pawns.

I call out the truck window in English to our translator. "What's going on? Does he want a bribe? Tell them I am a doctor and the child in the car is going to die and he MUST let us in."

More negotiation. The whimpering form in my lap is breathing rapidly and shallowly. My hand on her chest feels the fever burning through her thin cotton top, and the wild racing of her heart. She moans.

This is impossible. Yet, it is not. It is, perhaps, exquisitely predictable.

Less than a football field away from our truck sits a hospital full of medical specialists. Volunteers from all over the United States, giving of their time to provide free medical care to this city in its darkest hour. On my lap is a dying child. And between us is a wooden gate, and a man with a gun and a political agenda.

The airport authorities have apparently decided that the Miami Field Hospital, which sits on an unused grassy lot on the periphery of the airport, is an inconvience. And this week, after the US military handed back control of the airport to the Haitian government, public access to the only emergency hospital in Haiti has apparently been extremely and underhandedly curtailed. Hospital personnel report repeated efforts to obstruct patients' access to the hospital and emergency care - as we experienced on this night. A new unmarked entrance to the hospital, for example. A locked gate, with a belligerent guard. This political stand off -- so detrimental -- drew the attention of Haiti's President, who commanded the Airport Authority to allow patients through the gates and access to the capitol city's only emergency hospital. This was met, apparently, with political belligerance and opposition. And, at 2 in the morning, the power play is acted out. And the order of the country's Commander in Chief is disobeyed. And we -- the patient and her advocates -- become the powerless victims.

As I sit seething in the back of the truck, I evalute the integrity of the flimsy wooden gate which separates us from the lifesaving hospital visible beyond the trees. It is an absurd barrier of chicken wire and two by fours. I am certain we can crash through it with the truck if need be. My outrage is spurred on by the limp child in my arms. As I plot, I observe that the guard has a gun, and I fear he would be willing to use it. The images of several patients in our care flash through my mind -- innocent bystanders shot when the police fired wrecklessly into the ground around crowds in gestures of authority and intimidation -- striking bystanders with ricocheting bullets.

At this moment, I am impotent in my ability to help this child. We are at the mercy of this political agenda. An argument over a strip of land superceding the value of a child's life. A metaphor for the consequence of political ineptness and corruption.

I imagine this is how it felt on the night of 12 January, in the hours after the earthquake, when the sun left the sky and darkness fell. When the screams of the injured rang out, and access to medical care was, in a moment, non-existent. Hopelessness. Dying patients, in desperate need of surgeons. And no surgeons to be had.

I recall news reports of patients having amputations in city parks by the light of handheld flashlights...without anesthesia. I recall patients telling grim stories of being taken to the remaining local and overwhelmed medical facilities, lying without medical care, in rooms filled with dead bodies, themselves fearing that they would soon become just that -- another body, to be disposed of en mass in the back of dump trucks visible outside their windows. Desperate acts to save lives. Desperate patients. Desperate providers. Reflecting complete lack of access to care.
In Haiti's time of crisis, hope came in the form of volunteer field hospitals -- such as ours and Miami's. At the beginning, lack of medical access reflected the utter chaos of an unprecedented natural disaster. Now, lack of access is caused, in part, by political corruption.

Hints of such corruption were evident in my first week at our field hospital. Still on the forefront of the medical crisis, relief organizations were stunned to discover their medical and relief supplies being suddenly unexpectly being held ransom at the airport...many for tens of thousands American dollars. Donated medical supplies and shelters. For the country's injured and homeless. Provided free of charge from the generosity of the world community. To be utilized by volunteers, many of whom had paid their own way to Haiti to provide relief. Flown in by privately donated charter flights and international military flights. At the request of the Haitian government. Held at the airport and not released without the organizations first paying exorbitant and newly invented importation fees. While Haitians slept homeless in the streets of Port au Prince, enduring early spring rain without shelter; while the President of Haiti visted the White House in Washington, DC, asking for relief assistance for his struggling country... lifesaving relief supplies -- tarps and tents and medications -- sat undistributed in boxes at the airport. Our own hospital had its supplies held hostage for weeks -- including medications requiring refrigeration which sat sweltering in the Haitian heat.

And now, once again, the Airport Authority, blocks access to medical relief. In the form of this flimsy gate, and a man with a gun, who tells a blatant lie: "The hospital is closed. The doctors have left."

What will we do without a surgeon, I ask myself as I watch the negotitations. Turn around with this child? Bring her back to our hospital to die of sepsis?

Our midwife and translator continue to negotiate with the man behind the fence. Finally, they return to the truck. The guard, miraculously, manipulates the lock and slowly swings open the gate.

"Okay, he's letting us in," our midwife says, as she quickly puts the truck in gear, taking advantage of the sudden opportunity.

"Wait a minute," I say. "I thought the hospital is closed and everyone has gone home. Isn't that what he's been saying for the past five minutes. What did you do? Did you have to bribe him?"

Our Haitian translator turns to me. "He's letting us in because she's white," he says matter of factly, gesturing to our midwife. "You have to know how to work the system. It's just how things are here."

I am relieved for the girl in my arms, but absolutely infuriated for the people of this city.

"Wait," I say, as we start down the dirt road to the hospital. "Are you telling me that if I were a Haitian pulling up with a dying person in this car, that I would be turned away from the hospital?"

"Yes," he replied, absolutely.

"And we're getting in because we're white people?"

"Yes," he replied.

I am horrified and infurated by the injustice. But, for the moment, I am grateful for the incidental lack of melanin in my skin which, tonight (and, unjustly, through modern human history), has provided me with this seemingly random political advantage. I am perceived, by the color of my skin, to be someone who has possible political connections to a higher authority, a political democracy, which I can call upon to advocate on my behalf.

And for the local Haitian, who pulls up the the gate tonight with a dying child, without a political advocate? They will likely be turned away.

If you are reading this tonight from the comfort of your home, which fortunately is located in a representative democracy -- perhaps one of the wealthy first world nations which, through your tax dollars, has provided disaster relief to the nation of Haiti -- I ask you to advocate for those who are less powerful than yourself. Use the representative government that you are so fortunate to have peacefully elected, and which politically advocates on your behalf. Contact your congressperson or political representative, and ask that the government of Haiti be held politically accountable for properly managing their international relief; ask that further relief be contingent upon allowing that relief resources be accessible to its people. Ask that relief supplies be released to organizations on the ground helping their injured and homeless. Ask how your tax dollars are being spent, and how they are being managed, in this crisis.

And of course, because you perhaps would like to know the rest of the story.

So, we drove the remaining distance down the dirt path beyond the gate and pulled up to the front of the great white hospital tent. Father took his whimpering child gently from me and cradled her in his arms as we walked together from the truck, exiting the tropical Haitian night, and entering the front door of the still-bustling field hospital. Immediately, we were greeted by a doctor -- in fact, a board certified pediatric surgeon from Children's Hospital in Los Angeles. He gladly took her back into his care.

I guess the hospital wasn't closed after all. And, apparently, all the doctors had not flown home in the five hours since our last visit. I guess it was all just a simple misunderstanding.