Monday, April 19, 2010

City of the Sun

(Photo by Beth McHoul)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Until today.

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

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

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

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

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

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

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

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

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

I raised a cynical eyebrow in return.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Yes, Citi Soleil...

City of the Sun...

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

I'm boun' to love you.

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

Wednesday, April 14, 2010

The Depths

Photo by Dr. Jen Halverson

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

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

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

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

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

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

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

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

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

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


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

How does she survive?

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

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

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

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

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

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

His mind wanders again, this time to his future.

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

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

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

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

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

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

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

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

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

But just barely.

Friday, April 9, 2010

Keep on Survivin'

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

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

We'd hit a wall.

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

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

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

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

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

It became obvious that our patients have rhythm.

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

Then someone said, "No, really!"



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

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

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

But then, the magic happened.

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

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

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

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

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

Friday, April 2, 2010

Help One

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

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

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

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

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

I was on to him.

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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



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

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

He hugged us tightly. We hugged him back.

We walked away.

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


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

Thursday, April 1, 2010

Please Help Us Find a Neurosurgeon

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

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

Here is Amanda’s story:

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

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

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

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

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

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

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

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

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