Starvation

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?

Starving.

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..."

Starving.

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

Alleluia

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. What...you mean...tomorrow...like...the 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, Emmanuel...is all that remains of her family.

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

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

Alleluia.

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 prosthetist....so 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 in...it 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."

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?

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 death...is 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.

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 gate...no 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.

Injustice

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.

Whimpering...sobbing....in 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...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 surgeon...now."

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 care...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.

Food

It's 11pm and I'm sitting on the roof of the hospital. Above me are stars. Palm trees are silhouetted in the grey sky in the distance. A gentle cool breeze is blowing. Crickets chirp. The rural dog network sends barks from the east to the west and back. The crazy chickens still crow, although it is dark. The smell of burning tires/plastic/garbage which was so thick in the air today has eased, and the air is briefly refreshing.

I've escaped up here after my bucket bath to wash off the thick layer of dusty urban grime. The cold water was luxurious after the scorching heat of the day, removing a plaque of dirt embedded DEET ridden sunscreen that makes my pale Irish skin appear almost Haitian. Luxurious, that is, until the two inch cockroach ran up out of the drain and scurried across my wet feet.

Why...why...why.

It's just one of those things, at the end of a long, dirty, tiring day that drags a small, poorly-suppressed whimper from my clenched throat.

Ugh.

Of course, it could have been worse. It could have been the banana spider -- giant throbbing bulbous body, pointy spiny legs -- that apparently haunted the shower last week, before some heroic knight in shining armor intervened with a mighty shoe. I'll take the giant cockroach over the massive throbbing spider...but just barely.

There are giant rats out here on the roof, I am told, which apparently climb around and prey on the chicken coops out back, looking for an egg or two. I do hear the occasional scurry and crackling of leaves behind me. I will not turn around to investigate.

A mango just plopped down beside me...too small and unripe, unfortunately, for my own midnight snack.

Mosquitos buzz by, apparently giving my legs some consideration.

Everythings' out looking for something to eat.

Earlier today, we passed a giant line of people on the road to Citi Soleil. American soldiers stood guard, keeping order with impressive rifles. At the front of the line, a Humvee guarding a truck. The precious cargo in the truck? Rice. One by one, Haitians walked away, balancing sacks of USAID rice on their heads. Would the soldiers actually shoot those guns over a battle for a bag of rice? I flash back to the knife fight over tarps witnessed earlier in the week. Yes, this situation could quickly get out of hand.

Food. There is desperation in the lack of this fundamental necessity.

Later in the day, a mad rush of people passed our truck. They followed an unmarked panel truck, shouting animatedly. Men hung off its grill, sideboards, and back bumper, clinging to the rear door....like ants crawling on a jar of sticky honey. What was the precious cargo inside? Food.

Hunger...creates desperation.

Tent cities are growing. They creep up the sides of steep hills, guaranteed to wash away in the erosion of oncoming monsoons. They have spilled out onto the median strips of the main thoroughfares through the city. Spraypainted signs read: "Population 6,000. We need help. Necesitamos ayuda." Growing homelessness and poverty.

Goats line the sides of the road, snouts hungrily picking through discarded bottles and cans, amidst the stench of smoking garbage which has been, for some reason, lit afire. From the top of the truck, I do a doubletake and look down into a pickup truck below...full of dead goats, piled high, legs and torsos askew, heads lolling.. apparently being sold for food. The vendor met my eyes as we passed and laughed at my apparently disconcerted look...pointing vigorously at the goats and then to me.

"Want one?" he gestured.

"No thanks," I replied internally as I shook my head. "I'm trying to cut back on free range, garbage-fed goat..."

I shot him a salute. He bowed at the waist respectfully.

Did you know that newborn baby humans can survive on goat's milk? Apparently the only missing nutrient is folate. Who knew.

Mosquitoes feed on me. They carry malaria, Dengue "breakbone" fever -- a sometimes hemorrhagic, always non-treatable infection; and filariasis -- a microscopic worm which reproduces in the lymphatic system, blocking its flow, and leading to gigantic swelling known as "elephantiasis". I block them with 100 percent DEET. Nevertheless, they breach the chemical barrier and feed on me. I am covered with welts.

Many of the patients downstairs are covered with thick plaques of bumps across their hands, arms and torsos. Chronic scabies. Small mites burrowing under human skin. We treat them...but in this environment, the infection will likely recur.

What a crazy, interdependent, parasitic world, all feeding off each other. Just trying to survive.

Below me, an occasional splash. The tilapia -- an easy to grow, protein-rich fish -- flop about in their small ponds at the side of the hospital.

Downstairs, an elderly woman is dying of pneumonia...the single celled bacteria feed on the vulnerable tissue of her lungs. She has been weakened by the stress of the earthquake...and her immune system appears unable to compensate. She will likely die. We will do our best to make her comfortable, and give dignity to her passing.

Something is rustling in the dead leaves behind me on the roof. Time to retreat to my mosquito-netted bunk. Before I become something's midnight snack.

Please...if you are down there, Mrs. Banana Spider...it wasn't my shoe that squished your son... Really... Honestly.... Can't we all just get along?

Healing

This week will mark 2 months from the earthquake. And what I am seeing is remarkable.

How often does a medical person encounter such an enormous disaster -- 250,000+ dead and injured, all on the exact same day? I have trained in disaster response, when a car with four victims is overwhelming, an overturned bus of 20 patients a nightmare, and an airliner crash with 200 victims -- impossible. So, now, imagine twelve hundred airliners screaming out of the sky and crashing simultaneously down to earth...and into the poorest, most underdeveloped country in the Western Hemisphere. That was Haiti on 12 January. The airliners crashed and scattered the bodies. 250,000. Most dead. But many not.

Imagine laying in your slum, under a concrete wall, pregnant with both of your legs crushed. One of our patients did... for 3 days. Imagine laying on the ground outside of your home for 12 days with a pelvic fracture...bleeding internally and unable to move. In a city with no ambulance service...and now no hospitals. With no one to save you. Really. Stop and think. 12 days. That's longer than Christmas vacation...longer than your week at the beach. Imagine sitting on your livingroom couch for 12 days straight, immobile, without food. Impossible? Now, imagine doing it on the concrete ground of a dirty slum, your body shattered, sweltering day into smoky cool night, then repeat, ants crawling across your body, malaria filled mosquitos feeding on your dying form. One of our patients did.

Imagine wandering the streets with your injured 11 year old child, his face and eye orbit crushed with open fractures, seeking someone...anyone... to help you...and failing. This child -- now our patient -- finally found help four weeks after the earthquake, a massive orbital infection around his crushed eye. His face was so injured, and so exposed, for so long that when he was finally examined on the USS Comfort -- four weeks after the quake -- they found multiple bot fly larvae growing in the infected tissue around and behind his eye. Imagine four weeks of agony, without care. Wriggling larva burrowing into your open wounds to feed. Imagine if that agony were suffered by your child...and you were helpless to intervene.

Thank God for the first responders who went into the streets. The first volunteers from our field hospital -- who took our truck into the the depths of the slums -- and dragged back devastating injury after injury. Open fracture reductions by headlamp. Kitchen table top amputations. Desperate, life saving, life altering, interventions.

I was not here in the week after the quake. I did not see the initial devastation. But this week, I see objective evidence of their suffering. This week, we brought eight of our patients to another volunteer medical facility hosting volunteer orthopedists. With their imported c-arm x-ray, we were able -- for the first time -- to visualize these patients' shattered bones. In the weeks initially after the earthquake, many victims were splinted and casted for presumed injuries, based on the external appearance of their bony deformities. Xrays were an unavailable luxury. So, this week, for the first time, many of the injuries were defined.

I suppose you don't want to be the patient that causes the orthopedist to suck in his breath and whisper, "My God...look at that." Nor the one that makes him comment, "Unbelievable..." Nor, "No wonder she wouldn't weight bear..." as the c-arm xray scrolls up the leg and reveals a healing but angulated femur fracture. In my 12 year emergency medicine career, I have never seen so many dramatic, devastaing x-rays.

But the magic is, many were healed. Surrounding the matrix of shattered bones, hinting at a pain filled past, cocoons of tough white callous were visible.

"I know it looks awful," said Dr. Steve, the orthopedist, as he glanced at one particularly macerated tibia "but, believe it or not, it's sufficiently healed. Let her walk."

And so, through a translator, patients were told, throw down your crutches.

Walk.

You are healed.

After weeks of immobility, deep aching pain, disability, fear, hopelessness... sweltering long leg casts dragging in the tropical sun... the crippled were set free. And the announcement brought uncertainty and hesitation.

"My crutches..."

"You can walk without them, whenever you feel ready."

Hesitantly, castless feet touch down, lightly feeling cool ground again under now naked toes.

How amazing, yet perhaps not surprising, that when all injuries occur on the exact same day, that healing also completes, for many, on the exact same day.

The same is true for crush wounds. Skin grafts and massive open wounds have started to close. In the truck this week, I removed multiple dressings to find wounds finally healed. After 8 weeks of painful surgeries, debridements, grafts, and every other day dressing changes...many of the wounds were closed.

"Congratulations," I declare, time and again, grabbing a patient's hesitant hand, meeting eyes with a gentle smile . "We're done. You're healed."

Uncertain glances. Tears well in eyes. Hands hesitantly touch thick new scars...getting reaquainted with self, so long hidden under dressings and ace wraps. Tentative...

We, the truck crew, stand. And honor each individual.

"Bravo," we call. Then gentle applause. A pat on a shoulder. Sudden, dawning realization in a patient's eyes. A beaming smile.

"Merci...merci....." they say, repeatedly, as they rise to exit the truck. "Thank God...merci....thank God..."

And so they walk away.... from us, from our hospital, from our truck, from that day... back into their urban labarynth, to start their lives again.

Healing...

Alex

Alex, one of our truck medics, was thrown in jail this week. When I heard, my first thought was horror. Followed by a sudden guffawing laugh. Alex.

Alex is a 22 year old free spirit from Los Angeles, home schooled kid with 9 siblings -- including a few adopted Haitians. He came to Haiti after the earthquake to help however he could. He wanders the streets of the slums, speaking a mixture of Creole, French and English, wearing a hipster hat with a duct taped bill, cut off khakhi pants, skate boarder sneakers. When he removes his hat, his hair stands on end and askew, about three inches above his head, styled by fingers run restlessly through the strands. He is cool. Not intentionally, just incidentally. A humble cool. A brilliant young medical mind.

He hangs out on the top of our truck as we ride through the streets, occasionally twisting his foot into the metal bars in such a way that he can dangle off the roof suspended by just one leg. He and I have discussed the intelligence of this maneuver (or lack there of), and the accessibility of neurosurgeons (or lack there of), and the distance to the ground if he were to fall. He grins and shrugs. I keep my eye on him. I enjoy when he rides on the right side of the truck roof and I on the left. Because the left side of the truck overlooks the center of the street, while the right side of the truck gets slapped with tree branches and bushes and dangling mangoes growing on the side of the road. There is nothing more satisfying than watching Alex get slapped in the side of the head with a palm tree frond as we make our way through tree lined neighborhoods.

Alex, in his fearlessness, has ventured deeper into the slums than most of us might find comfortable. He is seen shaking hands and tapping fists with strangers, genuine yet casual smile on his face. We call him "the mayor"...a natural politician. And as mayor, he has had the most success tracking down people with orthopedic injuries. He knows how to activate the neighborhood grapevines. And in his ventures into the deeper labarynths, Alex has single handedly found at least four young women discharged from post-quake medical care with poorly healed femur fractures...who without resources, were left to lie on the floors of their homes with no hope of rehabilitation. He found them. And ultimately saved them...as they were returned to our hospital for curative surgery and a chance at a new life.

Alex rode the truck before I arrived in Haiti. So, on my first day in the slums, I was impressed by his popularity. In neighborhood after neighborhood, whether walking or riding, groups of children and young women call out "Alex, Alex!" as we pass. Our security guards mock him, calling out in high falsettos, "Alex! Oh, Alex..." Alex has seven wives in each neighborhood, one of our normally stoic and silent security guards advised me one day with a smile.

Alex likes to dangle by one braced leg off the roof of the truck, and will do so especially when the United Nations tank/truck vehicles drive past us. He enjoys the sudden startled looks on the faces under the blue helmets when he takes his pseudo-swan dive. Gives the poor fellas something to do, he says, as they drive around and around....which is what he's decided the folks at the UN do. They drive around and around in empty trucks. That is their mission in Haiti. Or so it appears, from the top of our truck.

Yet, he can be serious. It was Alex, along with our paramedic Chase and our nurse Morgan, who dragged an unconscious old man out of a drainage ditch full of human waste this week. The old man had been hit and run by a motorcycle. Open skull fracture, cominuted femur fracture....left for dead. And covered in sewage. Alex rescued him. And carried his lifeless body to our truck.

So, it was a bit of a wonder to hear that Alex was in jail. My first thought was, "Why?!!" My second, that I wished I had a cake mix and a file, because I think he'd appreciate the gift.

Turns out, Alex was asked to accompany one of the last remaining orphans from the Heartline Orphanage here in Haiti out to meet her new adoptive family in the United States. The tragedy of the earthquake has sped up adoption processes and facilitated a miraculous lifting of adoption beurocracy. (Alex himself notes that it took his family six years to complete the process of adopting his sister from Haiti.) Unfortunately, several American "missionaries" who chose to illicitly remove children from the country following the earthquake has led to caution on the part of the Haitian government in all subsequent legal adoptions. Now, all children leaving the country require a signature of the Prime Minister.

So, on the day of his departure, Alex was handed an official sealed packet of documents by the folks at the American embassy. Unfortunately, the embassy failed to include the document with the Prime Minister's signature. And, at the airport, with child in hand, documents were inspected, found to be lacking, and Alex was handcuffed and taken away....and charged with kidnapping.

After contemplating baking Alex a cake with a file, and realizing the ludicrous nature of his kidnapping charges, I came up with an ingenious plan. I imagined going to the streets of Citi Soleil and spreading the word of Alex's unjust imprisonment. I was certain, within the hour, I would have an angry hoard of residents en tow to help me storm the jail.

But before I could recruit my hoard, we were informed that Alex had been let go. The Consulate General of the US Embassy apparently went to the jail and negotiated Alex's release. Note, it was the US Embassy's paperwork error that got Alex thrown in jail to begin with. Which is why the comments of the Consulate General were incomprehensible to me. Apparently, the diplomat made something of a scene. He began yelling at the top of his voice, at Alex, in the jail. And bellowed something, to paraphrase, like the following:

"No wonder you were arrested. Look at how you're dressed! Do you think this is any way to dress to take an orphan out of the country?" He continued, "Look at your socks!! White socks? You should wear black socks if you want to represent yourself professionally." Then, finally, "And look at your hair! Do you call that an appropriate haircut?"

Alex, who came to Haiti with a backpack on his back, to serve the poor. No room in his bag for the apparently required tuxedo. Arrested, evidently, for wearing cotton socks and tennis shoes.

Let's be honest. What the Consulate General should have said was, "Look, I am a blow-hard, prejudiced, anal retentive beaurocrat who screwed up your paperwork, got you thrown unjustly into prison, and am now scapegoating you because I consider you powerless and naive enough to fear my ignorant rant. And by ranting, I remove attention from my own incompetent screw-up, and direct it, buffoon-like, in your direction. Do you fear me, politically powerless boy?"

Yes, Alex was freed from Haitian jail. And prejudiciously lambasted for his haircut. The beloved Alex of the slums, who spends his days volunteering in Haiti, pulling dying men from roadside sewers and crippled children from the ghetto. Chided by the second most powerful American in Haiti, because he failed to wear black socks to the airport.

Mr. Consulate General...you should be ashamed.

Thankfully, there is a thing called karma. So, the next morning, a freed Alex tried again. He gathered his paperwork, his small orphan girl, and made his way again to the airport. He still wore white socks and finger combed hair standing straight up atop his head. And this time, had the proper signatures. He boarded a private plane donated to fly 60 legitimately adopted orphans, and their escorts, to new homes in the United States. And delivered his precious package to her new loving home in America.

Turns out, the plane was donated by Sean Penn, actor and human activist. Who himself seems to have lost his comb a number of years ago... Mayor Alex (who'd never heard of Sean Penn, by the way), sat next to the actor on the way to the USA. He told Mr. Penn his story.

"You met Sean Penn?" I asked, when he'd returned.

"Yeah, he was pretty cool."

"Did you tell him what you were doing down here?" I asked.

"Yeah, I told him," Alex said, with his typical mellow humility. He shrugged. "He said I am a hero."

Yes, young Alex. You are.

Shelter

The rains are coming.

Today we drove the truck through the slums under gray, misty skies. The air is a beautiful 10 degrees cooler. The streets are filled with mudpuddles. And there is an air of hostility. There has been a shift in the morale of this neighborhood....for the worse.

There has been a delivery of relief supplies. Grey tarps emblazoned with the letters USAID are scattered on the streets of the neighborhood. I don't know how they got here, or to whom they were dispursed. There are some. But there are not enough. Our progress is slowed as we creep along amongst crowds surrounding these grey sheets of plastic. A screaming match. One man weilds a 6 inch knife. Another a set of scissors. They argue heatedly, gesturing with their weapons, cutting at the tarp, threatening each other. Other bystanders grab the plastic, and a violent tug of war ensues. Chaos. Over a sheet of plastic. A shelter from the rain. This is desperation. The scene repeats on street corner after street corner.

The tent cities have grown. I am impressed by the human ingenuity. I take note of the clever skeletons of would be shelters being erected on sidewalks and streetcorners. All awaiting a tarp, which will equal simple roofs and walls and privacy and possibly a bit of dignity. A small shred of dignity. And a barrier from the rain, which will soon fall relentlessly for weeks and flood the streets and overflow the garbage filled rivers flowing through the slums.

We make our way to our first stop, outside of a school. We come here three times a week to perform wound care on our regular patients, who somehow learn through the neighborhood grapevine that the truck has arrived, and make their way towards us on their crutches and in their casts. This is where the boy was dropped at our feet with a femur fracture on Monday. Here we practice performance medicine -- always in front of a gigantic crowd of boistrous, curious children, who surround us 4 and 5 deep and watch every move and every dressing change with fascination.

Somehow my identity has been revealed to the crowd, and children and teenagers peer through the metal bars of our truck, fingers poking through the painted metal mesh, and call out, "Barbie...Barbie...." Some of them poke at me through the mesh walls. I am like an animal in the zoo. "Barbie...Barbie. Hello, Barbie," they call, practicing their English. "Barbie...Barbie..." Poke. Poke. I tolerate it for several minutes as I inspect a deep wound. "Barbie...Barbie..." Poke. Poke. Poke. I finally lose it, turn around and say, "Barbie working!! Stop!!" They smile, having finally achieved my attention. "Barbie working! Barbie working!" they repeat. I close my eyes and shake my head with a smile. "Barbie...pretty! I love you!" says one boy of about twelve. Now, that's more like it, my ego says with a smirk. I turn and wink at him. He smiles. I continue at my work.

Suddently the children go silent. A strange sudden, disconcerting peace.

"What's the matter? What happenned?" I jump up and ask. Is it the tarps? A fight? Has someone been stabbed?

The children have left our truck and have moved 100 yeards down the street, circling something. They are silent. Then a sudden cheer is heard, as if in a baseball stadium...As if someone has just hit a home run.

"What the..." I ask, and jump out of the truck. Just 4 days ago, the center of this crowd's attention was a boy with a femur fracture. What can it be today? I arrive at the periphery of the crowd, and discover Morgan, the daughter of the heads of our Mission, one of the nurses on our truck. An all American, caucasian, freckled young woman with curly brown hair, raised in Haiti, fluent in Creole. She is jumping a thick black cable of rope swung rhythmically by two teenage Haitian girls. Urban jump rope. Fantastic. Girls enter and jump a few times, the rope going faster and faster, snapping loudly on the ground. They jump out. Rhythmic. Graceful. Others enter. The crowd is cheering. Morgan, laughing, comes and stands by me and Chase, our Los Angeles County Paramedic.

"Come on, Chase. Your turn."

Chase. An amusingly dry, sarcastic, highly competent paramedic, used to riding ambulance in the depths of urban L.A. Dressed in an LA Fire Department shirt, blue pants and combat boots. His full arm tattoos -- like gang symbols -- gain him more respect in this neighborhood. He shrugs, raises an eyebrow and says, "Here goes..." and jumps into the fray. Three grand jumps of the thick black jump rope. A hero. The crowd goes wild. He jumps out.

"I believe I'm perhaps the first white man to jump rope in the slums of Haiti," he says with great seriousness as he returns to the edge of the crowd. He wears a small smirk of pride.

Three graceful Haitian girls take his place in turn, stylin' at the jumprope. Then it's my turn. I'm pushed towards the rope...one, two...I'm skipping the big cord rope... three, four...Glorious....five, six.....The children are screaming joyously. The serious girls spinning the rope break into great smiles. I exit...exhuberant. Success. I am 6 again for a moment, jumping rope in my driveway with my sister. The children surround me like a sea, and pull me to the ground in a gigantic squirming pigpile. Their strange doctor, behind the cage, has entered their world, and can jump a rope. Squeals and smiles. These are the beautiful moments.

We grin as we drag ourselves back to the truck and climb up onto the roof. The children swarm about us as we slowly wind our way away. Hey youuuuu.... Hey youuuuu...... Their joyfilled cries fade behind us. They point. We point back. Hey you....

The rain begins to fall. We are getting wet up on the roof of the truck. I peer out over the tent cities. Tents made of cotton sheets flap flimsily in the the breeze. Tent skeletons of sticks and wire loom cachectically, tarplessly. Sounds of angry adults echo around us. Desperation. More battles over tarps.... We are all getting wet. All of us. We pass a spray painted sign on a metal gate which is the courtyard to a spontaneous tent community. In English, and Spanish, and French it reads: "Please, somebody help us...."

Food. Shelter. Water.

Absent.

Where are the hundreds of millions of dollars raised by the Red Cross for Haiti Relief? Where are your donations?

Isn't it ironic

Port au Prince is a city of hyperstimulation. Sounds and smells and sights, some so overwhelming and some mundane. They mix to form a strange, bemusing symphony of irony, cynicism, depression, laughter.... Like a fabulous curry, of never before experienced potent spices... Sensory overload.

Views from the top of the truck as we make our way back to the City of the Sun. A darkly dressed, intimidating man stands with a broad-legged stance in the back of a pickup truck which speeds to pass us from behind on the winding road; he wears a scowl and a pair of dark glasses. I would fear him, thinking him an intimidating gangsta' or security enforcer...until the truck passes and we catch a view of him from behind. He wears a pink backpack with a white Japanese cat drawn boldly on the back. "Hello Kitty!" I call out to him. My colleagues catch sight of him as well, and we all snicker.

We pass a partially collapsed building with the words "God is Good" painted on the front. Someone has climbed up the treacherous balcony and spraypainted the word "NOT" diagonally across the proclamation.

A now lopsided funeral home, with a crumbling facade, proclaims, "We treat death with dignity."

Ironically, a bit farther down the road, a fleet of large shiny-new white dumptrucks. The dump trucks used to remove the dead bodies from the city, I am told.

A sea of faces on the streets as we pass by. Heyyyyoooooooo..... Heyyyooooo..... I feel mildly anonymous in my perch atop the truck as we speed through the city. We pass a US Military HumVee with two tan, blonde, white, All American soldiers in the front seat. I stare at them and wonder what they're up to. From across the wide intersection, one soldier meets my eyes and waves, singling me out of the crowd. I wave back. A familiar face of a stranger from home.

We park at the neighborhood of the plastic bottle river. There is a pig and two children half wading/half floating through the debris. I look down at the bubbling black water and turn to Johnathan, our translator. "Would you like to try kayaking sometime?" I ask. In my mind, I imagine paddling through this sea of trash. Would my Eskimo roll be distrupted by a pig grazing on the floating trashpiles above me? "Uh, no," he says, looking at me with great seriousness. "Too bad," I reply. "I think this would be a perfect spot..."

We are stopped by a man with a rant. "Who do you think you are, coming in to our neighborhood? Do you think we need your help? We don't need you outsiders here." I am sensitive to and respectful of his point. Who the heck are we, this small group of foreigners, wandering through his neighborhood. Are we doing any good here? I think so. I hope so. But I understand his distrust of the outsider. A very human trait. I am reminded of living in Island Maine. If you were not born there, you were considered not from there....or, as the locals used to say, you're "From Away". Today, I am feeling very much "From Away." I am wondering if this community is transitioning through its stages of grief. Is today's stage, at least for some, anger?

We wander to check on a young girl, seen in our clinic two days before for a partial thickness, blistering burn across the entire backside of her dominant hand. It was debrided and dressed by our pediatrician yesterday. Today, she sits on her stoop and stares untrustingly at me. Perhaps because the procedure had been painful, peeling off the dead skin to prevent infection of the wound. I can see a crusting oozing mess which was once the back of her hand; it is now plastered centrally with a bluish/brownish crust.

"Oh, boy," I say to my translator. "That looks really bad...where is her dressing? Can you ask her what happenned?" An exchange in Haitian. Girl still appearing distrustful.

"She says her mother removed your dressing and put goat poop in the wound," said my translator.

"Goat poop?" I say with a near squeal. "Oh, noooo....why???"

"Voodoo..." says my translator.

I want to be openminded to alternative medicine practices. I cannot say that I have read the medical literature and the evidence based medicine on the use of goat poop as an antibiotic burn cream. I have not been privy to the controlled clinical trials. But, my western medical mind takes a pretty firm stance, on gut instinct alone, that this new fangled first aid creme will not soon make its ways to the shelves of American drug stores. I imagine writing that one as a script..."Apply a thick layer of goat poop to wound, BID x 7 days, or until infection resolves, #1, Refill: 2." It's funny. But it's not. Similar practices are performed around the world on the stumps of babies' umbilical cords -- animal feces are applied to dry up the cord; infants subsequently die of tetanus.

Child and family firmly resist offers to return to our clinic for further wound care. They will treat this injury in their way. I can do nothing but advocate gently, and then accept. I cannot force them. But I will return on Wednesday to see if this girl might subsequently need admission for raging cellulitis.

We move on to our second neighborhood. I am now in a funk. Are we making a difference here? I think so. I hope so. I want to respect local culture. I am aware of the importance of that. I do not want to come barrelling in like the ugly American, telling people to do it my way. But I do want to share what I know medically.

An old woman who now sleeps on the ground approaches with trapezius neck spasm. We are seeing tons of this same complaint....likely related to stress and awkward sleeping positions. She wants a pill. I try to show her how to do trap stretches. "Medicine!" she demands. "A medicine will last two days," I reply. "These stretches will last you a lifetime..." She glares at me. I am holding my hand on my head and pulling it laterally. I feel the stretch myself as a warm, satisfying pain down my neck. My sideways stare, like the sideways look your dog gives you when he just doesn't understand you, is met with distain. She shakes her head at me in disappointment and walks away. I am dejected.

We have a busy stop in this neighborhood. We remove 5 casts; tend to 13 healing skin grafts. Bones are healing. Wounds are healing. Perhaps we are not the ugly Americans that a few are perceiving. Would people do just fine if we were not here, I wonder. Are we just arrogant westerners From Away?

A man comes running to our truck, carrying a boy of 10 on his back. The boy is screaming in pain. He is dropped at my feet, and curls up on his side, wailing. We are surrounded by a sea of curious bystanders.

"What happenned," I ask. The boy is hysterical. And sweating. He grabs at his leg... "Why, why why....." he cries. Ironically, the Haitian word for "ouch" is "why". I actually find that a little amusing, a cynical commentary on pain, which is currently too familar to the people of this country.

"Where does it hurt?" I ask, trying to break through his hysteria. "Calm down. Point with one finger where it hurts." He continues to scream.

"Whyyy...why....whyyyyy....."

I try to touch his leg. He violently bats my hand away. He is rolling on the ground. I turn on my authoritative voice that I use for just these sort of patient encounters. The crowd has circled us.

"Look at me," I command. "Stop rolling and look at me."

He opens his eyes and they meet mine. Tears roll down his face. "Why...." he squeaks in a soft whisper.

"What hurts. Point with one finger."

He points to his knee. He watches me nervously. I gently pick up his leg and begin a knee exam. His thigh is dramatically swollen. When I test for ligamentous strength, his knee dislocates easily at a nauseating angle, and I feel bone on bone grinding.

Oh. I'm shocked. How has this happenned?

"He's broken his femur...and has disrupted the ligaments in his knee," I tell my team.

An exquisitely painful injury. Requiring a pretty sudden and massive force to achieve. Also a potentially deadly injury, due to the risk of large blood loss. We've seen too many of these in the days after the earthquake.

"We need to splint him and go now."

The boy begins to cry and scream again. "Why why whyyyy....My mother is going to kill me!"

Ha. Not funny, but funny. In the cloud of pain, he fears not for his leg, but the reaction of his mother. As we splint the boy, mother comes barrelling in, a large, forceful looking woman; certainly potentially intimidating, but nothing but motherly concern in her eyes. The boy does not have an exact story for how this happenned. "Playing soccer," he starts. Then, "I was attacked..." Trying to find the exact story to push mom's perceived anger into sympathy? He settles on, "I was attacked."

I hope he wasn't attacked. He has no details about who might have attacked him, and the story is fishy. I have a feeling he was climbing on something unstable in his neighborhood, amidst the teetering structures, and something fell on him. Perhaps a wall, or a block. Perhaps made unstable in the aftershock which shook the city again this morning. He is covered in sand and grime. Something he wasn't supposed to be climbing. Something his mother had told him, again and again and again. Something teetering, and waiting to fall, yet so tantalizing to a young boy in his very own neighborhood.

We load boy and mother into our white truck and make our way back across the city to the hospital. I kneel beside him on the floor and try to stabilize his splinted leg on the bumpy journey, checking his pulse for signs of impending hypovolemic shock from internal bleeding.

There is no emergency room or ambulance service here in Port au Prince, or so I am told. What would have happenned to this boy if we hadn't been in his neighborhood today? I am reassured that our presence here is still worthwhile.

*****

The Haitian government declared today that they no longer want their citizens to live in their makeshift tent cities. (Note that it was the Haitian goverment that initially encouraged the tent city formations.) Today, after no process of building inspection nor condemnation, they commanded people to return to their houses before the oncoming monsoons. Houses that are leaning forbodingly into streets, and angulated akwardly like my poor young boy's knee. Unstable buildings. With giant, cracks and teetering walls and crumbling ceilings. Houses just like those that we have seen fall, just this week, in the aftershocks of the earthquake. Houses that fall and crush children.

This declaration is insane. And unacceptable. I fear an oncoming second epidemic of "A house fell on me."