If you just smile

Three of the four nurses I flew with to Haiti left this morning, back to the United States. Beautiful spirits all. Mary and Carol are sisters, who came together to serve in Haiti. Sarah, a lovely young mother from Boston -- the other Boston...my childhood Emerald City Boston. Nurturing souls, found between IV pushes and medication administrations sitting on cots, holding babies, rubbing the backs of elders, hugging casted children. Humble women in bright colored scrub tops covered with hearts and flowers and Tweety Bird and peace signs. Peacefully soft in appearance, solid in a crisis. Our nurses.

Mary, a farm girl from Minnesota, full of surprises, revealed last night she sings in a jazz band. She said she had a dream to sing for the patients before she left.

"You sing in a jazz band?" I asked with a small bit of incredulity at yet another of Mary's hidden layers.

"Yeah," she said simply, with her regular humility.

"Well, what do you want to sing? Sing it for us!" I encouraged, as we sat crosslegged on the beds of our eight-bed medical staff bunkroom, darkness illuminated by a single fluorescent bulb on the ceiling. We leaned in, like teenage girls at a sleepover, in tanktops and scrub bottoms, legs folded up under us. "I want to hear."

She laughed softly, then admitted, "I don't know if I could get through it without crying...singing to all of them..."

"Try with us," I encouraged. "Come on..."

So, she started to sing, softly, a bit hesitantly, but then her voice strengthened to a deep, pure tone. Her eyes lit up. And words, so amazingly fitting for our patients, wafted over us..

Smile, though your heart is aching.

Smile, even though it's breaking.

When there are clouds in the sky, you'll get by...

I imagined her standing in the middle of the courtyard at our hospital in the evening when the patients gather for prayer. Soft spoken Mary. The secret jazz singer. Known only to her patients as the quiet nurse who so effectively cares for them. Breaking into deep, sensual song...A gift, a prayer, for those she has so selflessly been nurturing back to physical and spiritual health.

If you smile with your fear and sorrow,

Smile and maybe tomorrow,

You'll find that life is still worthwhile...

I imagine translating the words of the song to our patients, read in verse. Then have Mary sing, standing small yet powerful in the middle of the darkened evening courtyard. I imagine her patients, sometimes unable to know her true caring, due to the Haitian/English language barrier, finally seeing the truth of her deep feelings for them

If you just...Light up your face with gladness,

Hide every trace of sadness

Although a tear may be ever so near

Mary paused. Her eyes were welling with tears. "I don't think I'd be able to get through it without breaking down..." she murmured with a sheepish smile.

"Oh, yes you will!" I said. "You are going to do this! You will. Keep going!"

That's the time you must keep on trying

Smile, what's the use of crying

You'll find that life is still worthwhile...

if you just Smile...

Hoots and applause filled our bunk room. Hair on my arms stood on end. Mary the Jazz Singer Nurse. With the angelic voice... Wow.

"I don't know..." she said after the scattered claps faded.

"You will do it," I said with certainty. "Tomorrow night. Your last night. You'll do it. I'll make you."

We all smiled as we tucked ourselves into bed.

The next morning, nurse Sarah, who is considering becoming a midwife, and herself had a homebirth several months ago, announced that she wanted to help birth a baby before leaving the country the next day. Sarah had helped with our first challenging 3 pound, 17 day old neonate in distress, and demonstrated herself to be a competent, shakeless powerhouse. Another sweet on the outside, steely strong nurse on the inside, confident presence in a medical emergency.

"Oh, Sarah," I laughed. "You're gonna jinx us."

"I hope so," she said, and wandered away.

So, no great surprise, at change of shift at 7pm, a knock came at the large metal door at the front of our courtyard. Johnathan, our medical student turned translator, came running into the nurses station. "It's a lady having a baby! She's in labor! She's having a baby!"

The nurses and I looked at each other with raised eyebrows. Sarah folded her hands excitedly in front of her, a giant smile on her face. I shook my head in bemusement.

"Geez, Sarah," I said, "Will you now wish that I will win the lottery?"

A strikingly beautiful Haitian woman walked in wearing a flowing sundress, prominent pregnant belly attracting our attention. She calmly sat down on a cot as vital signs were taken. Only a small occasional grimace and a clenching of an eye indicated the pain of the labor, contractions 2 minutes apart.

A history was taken. Yes, prenatal care. Third pregnancy. Otherwise healthy. Laboring for 4 hours. Hoping to deliver with a doctor present -- not a common service available in Haiti, particularly after the earthquake.

Beth, our local midwife, examined the woman and recommended that she proceed to the birthing center, a few buildings down the street, where she is set up for traditional midwifery births. Nurses Sarah, Mary and Carol offered their services. As did I.

"Do you think you'll need any help? I'd love to help, if I'm not in the way," I said.

Ruth enthusiastically welcomed my offer to assist her. Our pediatrician Jenn also committed to being there in case of emergency.

So, the gaggle of women made their way to the birthing center. We changed into scrubs while the beautiful mother-to-be changed into a bright pink soft cotton t-shirt. Her gigantic pregnant belly protruded majestically, and she held it in her hands, eyes closed and quiet, riding out the intermittent labor pains.

I have never seen such a calm labor. Obviously painful, but most pain internalized. The occasional curl of her toes, or a small squint of an eye, a small unsuppressed grunt, a contraction of her pregnant abdomen, demonstrated the progression of her labor. But otherwise no external sign at all. Once again, the Haitian woman revealed what is appearing to be a gender specific and culturally nurtured ability to accept and process the deepest of pain that would leave lesser women (a.k.a. me) writhing and bawling and screaming for an epidural. Amazing strength. Built from a life requiring amazing strength, day after challenging day? Is this the type of pain the stoic women in our hospital endure as they relearn to walk on jagged femur fractures and pelvic fractures?

Five sweltering hours later, as a soft rain fell outside in the darkness, lovely mother squatted, then knelt, then lay supported in the arms of Jazz singer Mary, who from behind dabbed her face with a cool wet cloth, gently messaging her back. Then on all fours, then on her side, then squatting, then pacing. All the while silent. Father sitting in a seat next to the bed, likely overwhelmed by the estrogen swirling around the woman. Though unknown to us, this woman was taken into our care, like a sister. Held, like a sister in a universal and timeless tradition of birth. Back rubbed, legs messaged, brow wiped, whispered support. Doppler checks of baby's strong heartbeat...consistently strong and quick through contractions....a good, strong baby.

Dad was asked, "Do you want a boy or a girl, papa?"

Perhaps intimidated by the 6 sets of female eyes now pinning him to a decision, he smiled rather sheepishly and said, "Whatever....it doesn't matter." And shruged his hands. The women made approving sounds. He was off the hook.

The nurses in this room were not unaware of the metaphor revealing itself on this night, their last night in Haiti. The symbol of hope, in this natural experience of birth. I sat next to Mary on the bed, who sat behind mama, gently rubbing her shoulders in anticipation of another painful contraction. I fanned them both with a clipboard. I looked at Mary and catch her eye, and began to hum her song. Mary smiled, and we hummed together. Then she began to softly sing, "Smile...though your heart is aching..."

More time passes. It is 3 am. Mama is tiring, but labor is progressing. Now, a few moans escape her stoic facade. Then a gush of water. And an acceleration of labor.

Pushing, straining. Nurse Carol places a hand into mama's birth canal, and says, "Oh, I feel soft hair." Smiles all around. A tired smile on mama's face. Straining. Carol places hands gently at the perineum, and with another push, baby's head appears. She is suctioned. There is no cord about the neck. Another push and the slippery baby is out. A vigorous cry. A girl.

She is laid over mama's still swollen belly and we dry her vigorously. I have been placed in charge of baby's care, with Doctor Jennifer available in the room next door. I examine baby for signs of health. Initially pink, a good strong cry, and a fast heartbeat. Then, within moments, a dusky blue hue, no crying, slowed respirations, slowing pulse. No, I say. This is not how the metaphor ends. No.

Baby turns blue. We stimulate her with rubbing and foot flicks. We turn her over to open her airway. In a true medical clinic, we would have blow-by oxygen, but not in our small Haitian birthing center in this post-earthquake Haiti. We suction again. We pull out a pre-prepared ambu bag and breathe for baby, hoping to support her ventilations. Her heartrate drops further. The rule is, oxygen and bagging for heartrate below 100. CPR for heartrate below 60. Despite bagging, baby's pulse drops. My own accelerates. As a rule, it is bad when the healthcare provider's pulse is faster than the infant's. Time races. Our nurse gives artificial ventilations as I quickly initiate chest compressions on the now sickly blue baby. My thumbs cross over each other and squeeze baby's chest between my hands. "Get Dr. Jenn," I say with urgency as I stare down at the fragile bluish form, pumping her heart for her through the soft ribs of her small chest.

"Come on, baby..." I urge. I am reminded of just one week ago, and the 3 pound baby that was dying in front of just this very team of women. "Come on, baby..." Dr. Jenn appears. We continue ventilations and compressions. Seconds of purple lifeless baby stretch before us. No. This is not going to end this way.

Baby begins to perk up. Small arm motions. A cough. A weak cry. Pulse climbing. Stop compressions. Pulse 100. Stop ventilations. Baby breathes on her own. Her color pinkens. Now a vigorous cry. Another, louder cry. Female eyes meet each other once again over baby's now pink form, and deep sighs echo in the small birthing room. Eyes close briefly with relief and thanks.

Mama, who doesn't speak English, lay calmly as we fought for her baby's life. I believe she was unaware of the near crisis averted.

Again, I wonder what would have happened if this birth had occurred on a floor of a home, without medical support. Would the knowledge of the local women, and years of home birthing experience, have been sufficient to save this baby's life? Or would this have been another infant death?

"Okay, Sarah," I say, as she swaddles the newborn and cradles her in her arms. "Looks like you got your wish. You birthed a baby." It's four a.m. And the same women who stared down at the devastation that is now Port au Prince from a charter jet just 10 days ago, now coo and cuddle a pink newborn child. A fitting end to a fitting journey. A metaphor for new beginnings.

As she cleans up the evidence of the labor now passed, nurse Mary begins to quietly sing...

You'll find that life is still worthwhile..

If you just....

Smile.....

Hey Yoooouuu

This week I have been assigned to be in charge of the health care on "the truck". Our truck is a white flatbed with a roof and benches, enclosed by a cage -- not unlike an open air circus car. The roof is accessible by ladder off the back, and up on top, the best views of the city are to be be had.

Our truck goes deep into the slums of Port au Prince Monday, Wednesday and Friday. We are seeking out patients who would otherwise not have healthcare. The abject poverty here is beyond one's imagination. If you have seen Slumdog Millionaire, your mind might have a vague idea of what I am seeing. And most of the astoundingly squalid living conditions predated the earthquake of January 12th. The neighborhood, Citi Soleil, translated "City of the Sun", is broken into districts, including, ironically for an east coast native, areas called Brooklyn and Boston. As a child growing up in New England, Boston was the emerald city of my imagination, where we would journey for amazing adventures, like the aquarium and the Museum of Science. Now, when we say, "Let's head to Boston," my brain jolts; Boston don't look nothin' like this.

Shanty town. Cinder block walls and corrugated roofing interconnect into an exotic human beehive. A "river" runs through the neighborhood, perhaps 20 feet wide and filled 8 feet deep with plastic bottles, broken glass, garbage, human waste. Pigs wander over the floating garbage heaps in the river, rooting beneath bottles with their noses to find tasty morsels, like discarded chicken heads. A small girl walks with a white plastic bucket, presses it down into the garbage, and pulls out a blackened sloshing potion. She drags the bucket towards a cinder block enclosure. What is she doing with this water? Perhaps mixing it with formula to feed a new born baby sister, whose mother has learned through the miracle of billboard marketing that instant formula will make her baby plump and healthy...and so she discards the breast? Why doesn't the billboard mention that mixed with blackened riverwater, with pigs grazing on top of floating plastic bottles, this formula may cause infant death?

City of the Sun was once ranked the most dangerous city in the world, controlled by a network of violent gangs. In the past decade, it has become less dangerous, but is definitely still a place to enter with respect and vigilance. Today we drove to our first stop and climbed out of the cage of our truck and began to walk down a cement walk, trash river on our right, tent city on our left. Our small medical team is escorted by our Haitian guard. He is a pleasant, authoritative man, who speaks some English. He has told me he is from this neighborhood. He walks with authority along the cement footpath. He is given respect by the people, many of whom sit on the steps of their oven like homes in the blazing February sun. We have been told if we walk with him, we will be safe here. And we are. I don't know who he is, but I do know, to these people, he is someone. And I walk with him.

Adults stare with flat eyes as we pass by, but when I say a soft, "Bon jour" their eyes alighten and smiles meet their faces. The children, fearless, walk up and grab my hands and walk with me.

"Hey you, hey you" they call out in English.

"Hey, you!" I say back and point at them. They giggle. Some follow us on our journey.

Little boys run up to me with fists clenched in a greeting; I clench my fist and strike mine to theirs. They then strike their chest. So, I do the same. They find this very amusing, and look at each other and laugh. So do I. Little girls run past and touch me with their hands. I turn and make eye contact and they smile. One small child touches his hand then points to me.

"Blanc..." he says, pointing at his skin. "Blanc..." Translation: "Who's the white girl walking down our alley?"

We are greeted with nothing but respect. I am so grateful for this experience of Haiti. An experience of kind smiles and respect and gratitude, even in the depths of this slum. We are on a hunt for patients with casts and metal external fixators that hold shattered bones together. So many of these residents in this cinderblock shantytown experienced crush injuries. How many times have I read as their chief complaint in their medical notes, "A house fell on me...." or, "A wall fell on me." The evidence is here in this neighborhood. Today, two small cinderblock houses have been flattened, lying strewn across the garbage river and onto the walking path. On Monday they had stood erect. They were flattened by the aftershocks that had awoken me from sleep 2 nights ago. Tarps have been erected, emblazoned with painted words, like USAID and Red Cross. Families sleep inside -- elderly and newborn. Some shelters are mere cotton sheets, which will disintegrate in the oncoming monsoons. But the decision to sleep outdoors is, for some, the right decision, with teetering buildings and walls surrounding them.

We find a boy in a cast extending down both legs and up his torso -- treatment for lumbar fracture and lower extremity fracture. It is a bright green happy color, now grimy from the dirt. We find a young woman walking on a painfully deformed ankle -- having never received care, six weeks after her injury. Another with a cast.

"Who put this cast on," I ask.

"I don't know," said the young man.

"What did you break?" I ask.

"I don't know," said the young man.

I inspect the cast and imagine the fracture it contains. And here is the epidemic we seek. People treated in the days after the earthquake by goodwill filled international surgeons and released to the streets. We find one discharge summary which reads, in Spanish, "Follow up with your orthopedist in two weeks." Yes, follow-up with your orthopedist. If you are literate and can read this note. And can speak Spanish (which you don't, because you speak Haitian Creole). And can afford to see an orthopedist. And can afford to take a taxi to his office. And his office is not now 5 feet high because it collapsed in the earthquake.

In other words, we are now seeking out the patients who now are 6 weeks into healing, trapped potentially indefinitely in fiberglass casts and surgically placed metal fixators that protrude from their skin and track bacteria back into their bones. Orthopedic surgical cases who have no follow-up, and who are therefore destined for infection and possibly even death in these squalid conditions. In each neighborhood we gather these patients, clean their wounds and skin graft sites, take care of their jutting orthopedic hardware surgically implanted into their bones through their skin. We find these patients by walking through the neighborhoods, asking if anyone in the neighborhood has a cast, or crutches. We sit on top of the truck and drive through the neighborhoods, hunting for bright colored fiberglass casts.

On this day, in our hunt for a woman rumored with a leg fracture, a man calls out that there is a woman down the alley who gave birth last night, and that she is having severe pain. So, with our guard to guide us, we wander down the concrete path, take a footbridge over a garbage river, and wind our way through the labyrinth of cinder block lined narrow footpaths which is the slums. We pass a woman chopping the head off a chicken, and come to a small darkened door. Inside the oven-like one room home, a woman lays supine on a bed, holding her belly. Her new infant child lays sleeping by her side. Through a translator, I ask how she feels.

"Fe mal," she moans, rubbing her abdomen. "It hurts."

She is feverish. Likely uterine infection. Her baby is sleeping.

"Have you breast fed your baby?" I ask.

"No," she says. "I cannot make milk." Images of formula made with black river water flash in my head.

My nurse colleague checks the baby. Slightly tachycardic -- from mild dehydration, or early life-threatening sepsis? We take mother and child, and backtrack through the slum. If the man had not alerted us to this woman's presence, it is very possible both mother and child would have succumed to infection, and possibly, ultimately, death. We walked her to our truck -- as she, with dignity, refused to be carried -- and drove her to our courtyard tarp hospital. Two lives, possibly, saved.

We head out again to the slums. This time, we ride on top of the truck in the open air. We need to be careful for the occasional low-lying power cord and errant tree branch which could knock us off our stoop, but from here, we again see another Haiti. We can see over the concrete walls from this vantage, into tent villages behind. From Monday to Friday, the tent cities have grown. Probably due to the frightening aftershocks. We pass bustling streets, with many street vendors -- some of whom have set their sidewalk shops just in front of teetering buildings. One more unpredictable rumble and more "A house fell on me" notations will appear in the medical charts.

"Hey you, heyyoou, heyyyyoooooo" children call out in English and point. I decide my new name is Hey You.

We stop in four more neighborhoods. Our truck is recognized. We are "the doctors". Children and adults and elders limp towards us, some with crutches, some carried. We perform their every other day wound care on healing legs with horrific wounds. Dark Haitian skin reveals the white scarred extent of injuries already partially healed. So many, many scars.

We are called to a medical tent run by a young Italian pediatrician. She speaks to me in Italian, and then when that fails, Spanish. Spanish! My lips open, and I am communicating with an Italian physician in Haiti in Spanish. Fabulous. She points to an elderly woman -- skin and bones -- slumped against a pole. Her son sits at her side.

"She is very ill, and I have no way to take care of her," tells the Italian woman. "I can only care for children."

I tell her we will take this woman, and that we will be back every 2 days, and will take anyone she finds needing adult or orthopedic care. We shake hands and each nod a respectful, "Adios." How did she get here, I wonder. I wonder if she wonders the same about me.

We lay the elderly woman in a stretcher and lift her into our truck. She is too weak to lift her arms. She is starving. She is dehydrated. She is feverish. She appears to be dying. She opens her eyes and stares at me. I have a plastic bag of emergency relief water. I cut off the end and pour trickles into her mouth. She drinks thirstily, her dark hand over my pale one. I take her other hand and hold it as we work our way through the streets back to our hospital.

From the squalor of her slum, we carry this woman into our courtyard. In fear that she has tuberculosis, we make her a small tarped area of her own on the distant part of the yard. We choose a spot next to a cluster of palm trees. A wondrous campsite, in my experienced camper's eye. By now, it is nighttime. The patients have begun to sing their evening prayers, a mixture of song and energetic rhythmic spiritual clapping. By the light of headlamps, my nurse colleague Deb and I draw blood, start an IV, and do basic lab tests. A swab of her inner lips and a two minute test reveal this woman has HIV. Likely AIDS. Likely TB. And is on the verge of death. We get her a warm blanket for her nocturnal chills. Nourishing fluid enters her parched body. She rests comfortably in our clean, warm courtyard, palmtree swaying above her, beautiful Haitian song wafting gently about her, warm tropical breeze wafting past. If she dies tonight, I am glad that we could give her this night in this peaceful world of our beautiful makeshift hospital.

Through a translator, I speak to the weak old woman and her son. "I don't want you to feel bad because we've placed you away from the others. You have an infection, and we don't want to possibly spread it to others. It's not that we don't like you..." I said, holding her hand.

"No," said the son. "No. We know. We understand. You have already demonstrated your love."

3AM

I am on call at the hospital tonight, lying under the mosquito net on the lower bunk of the on-call bunk bed. When I lie down, my headlamp illuminates the handwritten message taped to the bed above. "Don't let the bedbugs bite," it advises cynically, with an an inky illustration of a small swarm of insects surrounding the words. My legs begin to itch. This is a fascinating world of insects, tropical medicine and infectious disease...as long as the patient is someone other than myself. I just awoke to deal with a patient retching with vomiting and diarrhea. The next stage of this Haitian crisis -- people now malnourished and immunocompromised from stress -- will be infectious disease. And an outbreak of diarrheal illness in our hospital -- with one patient bathroom -- is something I would prefer to not imagine.

I would rather awaken to a patient's illness than the earthquake aftershocks that hit us the two previous nights. Like a scene from the exorcist, three times I have been stunned awake by my bed shaking beneath me. These 4.7 level aftershocks lasted 15 seconds or so and were accompanied by a deep groaning rumble from underground, like a moaning demon crawling below the house. These sounds and sensations make hair stand on end and are the things from which nightmares are born. Each time coming awake, I found my heart racing, like my adrenal glands instinctively dumped adrenaline in preparation for flight...even before I awakened. According to our night nurses, the clinic dogs were able to anticipate the quakes and barked excitedly several minutes before the actual aftershocks hit. Images of leaning buildings and our crushed patients spiraled through my mind as the ground trembles.

How do these psychologically and physically battered patients tolerate this frightening rumbling? I think of one, trapped for 12 days in the rubble, pregnant and crushed with multiple lower extremity fractures. What went through her mind as the earth repeatedly rumbled like a demon below her? Absolutely terrorizing. In the first 10 days she was trapped, more than 50 aftershocks shook the city. The aftershocks are more horrifying for the small children, unable to intellectualize. Like a child myself, I found myself pulling my sheet up closely under my chin, despite the tropical heat, calling on the protection it used to provide me from monsters and vampires and the thing that lives under the bed. This monster under the bed this week is a bit too active for my taste.

The unpredictability of the aftershocks frays already raw patient nerves. After the second aftershock last night, our inpatients began screaming and crying out. Those housed under the concrete overhang of our courtyard -- 15 patients with severe ortho injuries -- instinctively began to run or pull themselves to the outside lawn, screaming and crying. Many Haitians will now not live inside...for many, a wise choice. Out clinic is structurally sound, per the review of a privately paid structural engineer. What do we do with a country of terrorized patients with PTSD, I asked myself, as I myself stood outside in the courtyard in my bare feet at 2:00am after the second aftershock... emotionally shaken.

But tonight, so far, the only threat is bedbugs. And diarrheal illness. And the annoyance of chickens crowing in the dark in reaction to the inadvertant shine of my headlamp into their nests as I gaze out the window. Sorry chickens. It's not morning yet. Go back to sleep. And so will I. Don't let the bedbugs bite.

5 Weeks Out

It is 5 weeks and two days from the earthquake.



Today, Rosemond-- a 5 year old who lay in the rubble for 3 days next to his dead parents, with a skull fracture and crushed extremities --awoke and began to rock and sing softly in Haitian, "Mama, Papa, dead...Mama, Papa, dead..." I learned this when I took him to change his dressings. 5 weeks out, wounds and skin grafts are slowly healing. But, this normally amazingly bright and smiling child -- definitely the shining star of our hospital -- for the first time since I met him, failed to meet my eyes. 5 weeks out...today...he proceeded into the next stage of grief. Through a translator, with a downward gaze, and uncharacteristic tears in his eyes, he whispered it again. "Mama, Papa, dead." His translator, a Haitian speaking American nurse, crouched down to meet his gaze, put her arms around him, and whispered reassurance. He then took my hand and came to the examining table. Rosemond is normally exquisitely curious, opening zippered pant pockets and plucking objects from my fanny pack with a grin. Today he does not engage. I pull my camera from my fanny pack and hand it to him. He normally pushes the buttons in fascination...small movements encouraged by our physical therapist to rehabilitate his partially paralyzed right arm. His gaze is lifeless. I squat down and take his photo. (I've attached it here. You don't know Rosemond, so you perhaps won't notice that the light is missing from his eyes.) I show him his photo and laugh. A small smile reluctantly curls one side of his mouth. I hand him back the camera and make a crazy face. With his partially paralyzed hand, he reluctantly takes my picture. We look at it and giggle. Then our pediatrician Brad turns around and makes another crazy face; Rosemond giggles, and takes another picture. He then proceeds with a photoshoot of our "emergency room", capturing picture after picture of our staff, and his smile reappears. Click...look at the photo. Click...look at the photo. He is smiling again. His spirit is transiently reignited. I give him a one armed hug, and change his dressing while he unzips the front of my fanny pack to explore inside.



Haiti slowly recovers, yet the depth of its wounds is truly unfathomable. Today our new staff took to the streets of the city in a truck driven by the head of the orphanage turned tent hospital. He is an American who has lived in Haiti for many years. This is his home. He gives us this tour intentionally, so that we can see the devastation and share the story. It is an education. We pass vast tent cities -- some of 40,000 or greater population. Port au Prince had a population of 2 million before the earthquake. There is an estimated 200,000+ dead. Many bodies remain in the partially collapsed buildings. The number of injured are innumerable. Many residents fear returning to their buildings. As far as people here are aware, there is no government program to evaluate the integrity of the structures. So, buildings and walls hang sideways and precarious, many looming dangerously over sidewalks now once again populated by pedestrians and street vendors. People are seen climbing on the tops of partially collapsed structures, sitting on teetering balconies, sitting in plastic lawnchairs on piles of rubble, clawing through crumbled walls to retrieve possessions. At 20 to 30 miles per hour with my small handheld camera, I snapped photo after photo. In a one hour tour of the city, I began to wonder...how many photos can I take of partially collapsed buildings? The fact that it has become monotonous is insane. We pass the National Palace, which has partially caved in, and stands lopsided, Haitian flag still flying at full-mast. It is a metaphor and horrific reminder, and is contrasted by the large tent city which has been erected across the street.

Our host stops the car and rolls down the windows in front of the tent city. "Stop and breathe that in," he says of the humid, tropical air, nauseatingly saturated with the scent of human waste, garbage, and possibly more morbid substances. "Now, imagine living there." The plan for deconstructing and rebuilding is unknown. The monsoon season is 3 to 4 weeks away. Followed later by hurricane season. And the plan for long term, safe housing is unknown.

Of the tens of thousands injured, we have 30 in our hospital. And see many more each day in walk in clinic. And even more in our drives in our mobile clinic around the worst parts of the city, inaccessible to public transportation. We are only scratching the surface. Included in our tour today, was a collapsed nursing school, in which many of its students lost their lives, a collapsed medical school, a collapsed hospital, and a collapsed dental clinic -- the past and future of Haiti's medical system.

Today I discovered one of our translators -- a bright and incredibly positive young man -- was a second year medical student. His medical school was destroyed. I asked him what will happen now to his educational plans. With downcast eyes, he said quietly, "I do not know." Another bright presence in our hospital. An amazing spirit. Another extinguished spark. He stared at his shoes.

"Would you like to learn how to start an IV?" I asked him. His eyes shot up and met mine. The spark returned.

"I would love that," he said.

"We will teach you while we're here," I said. "For now, let us be your medical school."

He smiled and said, "Okay."



*********



If you would like to make a donation to Haiti relief, consider Heartline Ministries http://www.heartlineministries.org/, with whom I am volunteering -- a well established, well connected local non-governmental organization with strong ties and strong respect for the Haitian community.

Looking Up

This morning, walking down the muddy road from our host home to our field hospital, I happened to look up, and realized the trees gently shading the morning sun are laden with mangos. Luscious, soft, sweet, heavenly fruit. And they appear to be everywhere...when you take the time to look up. Then I spotted the bananas dangling with tantalizing promise. Then flowered tree limbs that stretch out from behind crumpled walls, wafting a sweet purple scent down onto the street in greeting, transiently blocking out the odor of burning garbage. Why did I not see these things yesterday? People walk past with soft "Bon jour's" and kind smiles on their lips and in their eyes. The things one sees when one lifts one's eyes from one's feet.

We arrive at the hospital and the question of the morning is, "How is the baby?" -- the 3 pound dying infant from the night before. "He's alive, and breathing on his own..." are the words that create a good start to the day. The sick child was found in the arms of his mother in the crumpled slums last night by our astute medical team, who had spent the day in devastated neighborhoods looking for ill patients unable to access care. If he had not been plucked from the streets, he would now be dead. And now, he will live. I wonder what he will become. And, what will become of so many of these children...the fragile future of this country.

In walk-in clinic today, a young girl with a healing severe leg fracture. She had been trapped under rubble, her leg crushed. Doctors had recommended amputation - a harsh but necessary triage strategy to save the lives of the most people in the absolute overwhelming devastation in the days after the earthquake. Life over limb, when there is no time for delicate, intricate orthopedic surgery, when hundreds of others are lined up needing the same life-salvaging care.

Her family had refused the amputation. They took her to another field hospital. Again, the recommendation was for amputation.

"I cannot have my leg amputated," the girl had cried, pleadingly. "My mother would be so mad..."

So, the family found a third orthopedic field group, who, reluctantly, per family's demand, attempted to salvage her mangled leg. And as of today, miraculously, one month from her injury, her leg appears to be slowly healing. Impossible. Yet happening.

The girl grumbles at our ortho PA, who insists she stay in her cast, on crutches, or the bones of her leg will likely collapse. She is getting intensive fracture and wound care here, including honey dressings -- a natural, locally available antibacterial wound covering which keeps out the germs of the dusty Haitian streets. She is doing incredibly well. Yet she is frustrated.

She hates her cast. She crosses her arms and pouts. She wants it off. She wants to walk. So far, one month of pain. Crutches on the rocky muddy streets of Port au Prince. She is mad. She glares angrily at the ortho PA, who tells her she may need the cast for 1-2 more months. She seems unaware of the miracle which is her healing leg...as others mere yards from her lie with their healing amputations. She gets on her crutches and storms away, as only a preadolescent can do.

I laugh silently to myself, as I watch her hobble angrily away, and think, "Oh well, she's mad, and that's okay, and she is healing, and that is good..."

Then, suddenly, she turns back around, storms back over to our ortho PA, glares at her for a moment, then leans gently into her, rests her head on her shoulder, and wraps an arm around her waist.

"Merci..." she whispers, and looks up at her with wide brown eyes and a reluctant smile. Then turns to leave again.

Beautiful.

I, too, have received several of these hugs today. One from a little girl of five. She plays with my wristwatch, pushing buttons and cleverly changing the time back to Alaska time and the settings to a 3:02 am wake up alarm. Nice. I start to tickle her to get her to stop. So, she wraps her arms around me, hugging me fiercely, cheek against my side, eyes tightly clenched. Then she looks up. She rests her chin against my hip, and quietly stares up at me with a piercing child smile.

The osmotic flow of love.

It is a long day. But a good day. As I walk out into the street from the hospital, it is dark. Up in the sky, I see the comforting familiarity of stars twinking through the lattice of purple flowers and a million mangoes.

Note to self...even in hard times, remember to look up.

Love

Yesterday we were strangers. Five of us -- replacement medical volunteers -- flew over the wreckage of Port au Prince in our charter jet, filled to capacity with donated medications and medical supplies. The devastation of the earthquake was overwhelming from the air, stretching miles beyond the boundaries of the tightly packed city. Structure upon structure visible from above, collapsed and toppled. Overwhelming.

I recall playing monopoly as a child with my sister...when the game got out of hand, and tempers flared, and the hotels and houses were lifted and thrown askew when a frustrated hand slammed down upon the board. Whose great fist slammed into Haiti on January 12th, 2010? Why? Overwhelming.

We rode in the back of a truck through the streets from the airport. Air was thick with the smell of burning garbage. Passports stamped in the archway of the now abandoned airport facility , gigantic cracks splitting the face of the building serve as a a first sign of the earthquake. We pass the massive white tents of the Miami Medical Center's field hospital -- Port au Prince's temporary ED. Piles of rubble where mason walls used to stand. Roofs of buildings now 3 feet high. Who was crushed inside in an instant when the fist fell?

We arrive at our field hospital as the sun sets. 30+ inpatients silently watch the newcomers enter the darkened courtyard-turned -tarp covered hospital. They are quiet, respectful. Tired. Blank faces. Kind faces. Traumatized, inward looking faces. A community of injured, cots several feet apart, some sleeping, some consoling one another. There are babies here -- a tiny infant born by c-section from a mother with an open book pelvic fracture; mom was flown to the USS Comfort. A miracle. Baby survived. A miracle. Mom is learning to walk again, slowly by slowly. Casts and amputations and metalic external fixators protruding from the skin of broken limbs. Bandaged children. Dogs wander about and sleep in curled up circles. A boy recovering from a skull fracture...found in a crushed building days after the earthquake, his dead parents by his side. The stories go on an on.

Many had emergency surgeries in the days after the quake and were released to the crumpled streets. Our hospital sends a truck into the neighborhoods every other day to check on patients we can find...lying without sanitation on tent floors with healing surgical wounds and protruding metal hardware, new infections, new babies, diarrhea, malaria. And, of course, the emotional shock and devastating loss. Blank eyed patients with no families left, homes now rubble. Children with massive injuries, recovering from massive life-saving surgeries. Many orphaned. Frightened. Emotionally devastated. Some with amazing, beautiful smiles. One boy, now orphaned, with a non-functioning right arm and a large head wound, smiles at me and teaches me a secret handshake with his left.... touch fists straight on, above, below and then strike the chest. We practice till I get it right. He giggles. I giggle. Did his father teach him that? Who will be his father now?

So many femur fractures and pelvic fractures and amputations. Gigantic forces cause these injuries. Gigantic. So many stories of these patients trapped for days before being found. And now here they are, in our gentle tree lined courtyard under the stars. A mix of American medical volunteers, yesterday strangers, today making it work somehow.

Today our medical team found a young woman with a 17 day old baby in the field. A three pound baby. The baby was dying. Dehydrated. Heart rate and oxygen level and glucose dangerously low. Small red spots of petechia -- meaning life threatening infection -- appeared on his body in front of our eyes. Together our team, led by our physician, a volunteer pediatrician, with innovation and urgency, were able to stabilize him with our limited supplies. We packed his fragile body into a truck and drove to Miami tent hospital, begging them to take him to stabilize him with their more advanced tools and supplies. The tents have perhaps a hundred patients each. The staff are exhausted. They take the baby. Overwhelming.

The world needs to hear -- as I did tonight -- the strangled, sobbing wails of a young mother, who fears for the life of her dying infant, one final loss in an intolerable string of losses. The deep, soul-baring, sobbing wail of a mother losing her only child, going on and on, mile after mile, in a darkened truck, street after crumpled street in the tropical smoky night. The world needs to hear this. Infatiguable fear and grief.

It is the sound of the devastation that is Haiti.

In the dark, we returned from our journey to our field hospital, our souls now overwhelmed with the young mother's devastation. As we opened the metal gate from the dirt road, in the darkened tented courtyard, we found our the patients singing loudly in deep prayer, arms raised and swaying over their heads. They had called the medical staff to the courtyard...and were singing to them. A deep soulful harmonious blessing. Nurses stood, stunned, eyes filling with tears, as their patients -- broken, suffering, tormented -- rose up in song, honoring them, praying for them.

So is the sound of the soul of Haiti. The sound of suffering and pain. The sound of hope, and joy, and love, and strength. Haiti...Such a strong word.

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