Women Inside Haiti's Hospital
Day six: Because of a Haitian government directive, we now have to abandon our plans to continue to provide care in the massive sheet cities. We're a team of Bay Area healthcare providers, and this is my first ever relief work. When we worked in the sheet cities during the last days, I'd been amazed at the women of Haiti, amazed at both their suffering, and their strength. From now on, we'll work in a hospital, instead, and last night our organizers found one, named C.D.T.I. - a hospital that had been one of Haiti's premiere private facilities, now open to all, and in need of help from providers. As our bus neared this new hospital setting, heading closer into the epicenter of Port au Prince, the conversations on the bus drifted and died. Even accustomed as we were by this time to the sight of widespread devastation, we blinked as we rode through this increased level of destruction. We'd seen two-story high piles of imploded rubble before. We just hadn't seen so many of them, one after the other, with tilting walls that looked barely tethered by a thin leash of rebar, looming over us as our bus rocked past.
Further in, the air thickened into visible, eye-watering pollution. The haze of drifting dust, the black greasy smell of diesel, and the ever-present nauseating cloy of decaying corpses had us, despite the heat, closing bus windows. Traffic crowded and wove all around us, snaking and writhing past – zipping moto-bikes, jeeps with people hanging off the sides, and overpacked garish metal-seated buses. Between the smells, the heat and the traffic-induced vertigo, I flushed and felt my stomach lurch – I could almost feel each fleck of chewed mango slosh in the shallow puddle of inta-coffee-fake-milk mix I'd had for breakfast – and I wondered if I was going to spend the day in a corner of Haiti's premiere private hospital, hugging a plastic emesis bucket.
We turned a corner and a tall, narrow sign, still upright after the earthquake, proudly proclaimed C.D.T.I.'s location - and it's hours "Open 24/24, 7/7.” The hospital, like almost all Haitian structures of any worth, was surrounded by a prison-grade wall. It was clear our bus wasn't supposed to go through the metal gates, so we parked around the block and walked in.
The gates actually were the entrance to the parking lot, which had become, since the earthquake, the emergency room. The hospital, beautiful and modern, had mostly withstood The Day, but the air was filled with the constant scream of saws, and you could see, inside the massive, glass-walled round turret, the constant flicker of welding torches.
The parking lot was covered with massive suspended sheets, like the food-court areas in American amusement-parks. People, even at this early hour, seething and moved and limped and wove between each other. It was hard to tell who was doing what, or why, the patients, staff and medical personnel all following invisible paths, like watching an anthill. There was clearly a pattern, we just didn't know it yet. Instinctively we moved to the one open-air space. And found other relief workers, also shifting from foot to foot, a hand shading a face, a low murmured word to a colleague nearby.
We didn't know what we were waiting for, or for how long. But by now, after six days working in Haiti, we didn't fret about it. We just waited, eying the patients who milled into the area around us, all of us undoubtedly thinking about who looked the sickest, who needed to be seen first. The patients - limping, walking, or being carried into the parking lot area through the gates - ignored us as we stood in an obvious circle, all of us wearing scrubs, proclaiming our foreignness in many ways, but the most obvious one being that we were standing out in the sun, off to the side, when there was perfectly good shade only a few steps away.
For the first time, while we waited, we saw American military, a few of whom were painfully young-looking. They wore camouflage, carried a casual shoulder-strapped machine gun, walked in heavy boots through the crowds - who easily and widely parted without seeming to ever see them. There weren't many soldiers, but you clearly didn't need many. Before we could stop ourselves, a few of us gave them a happy wave. They ignored us, except for a stern micro-nod or a half-smile one or two couldn't quite completely suppress before it slipped out. It was a chilling reminder that these soldiers were here with the expectation that a riot could break out at any moment, that they could, humanitarian mission or not, die and/or kill someone, and that they weren't supposed to be distracted, even in a hospital, even by a fleeting goofy wave of hello from a fellow American.
Dr. Choi returned, and with him was a woman in blue scrubs who shouted to us to gather closer. Her name is Kate, and she gave us a brief orientation, which consisted, like a restaurant's menu, of what was on offer today. Radiology? Sure, at least for now. Labs? Maybe, depends on the type. Surgery was happening, and some drugs were available. There was momentary digression when Kate and Dr. Choi got into a laser-focused bargaining session about which pills we'd brought with us and how many the hospital could keep when we left. Deals in starved third world markets have been struck with less intense haggling. Then Kate continued the orientation as though nothing had happened. And the entire time Kate oriented us, even during the bargaining, she didn't seem aware that she spoke with her palm of her left hand pressed against her forehead, like a portrait of a woman grieving, or a woman close to collapse. We discovered that she is a trauma surgeon who arrived in Haiti two days after the earthquake, expecting to be here for only a few days. She had no skills, or training in hospital administration, but, six weeks later, she was still here, running this hospital, swaying as she talked, hand pressed to her forehead.
Incredibly, Kate explained that each and every day, she had no idea who would appear to work. Sometimes medical teams said they would show, and never did. Sometimes people would magically appear with no warning. Sometimes people came but then left before the time they said they would. The operating room schedule was made up each night based on which patient needed surgery, without any idea whether or not a surgeon, anesthesiologist and/or nurse would, or would not, appear. Basically she ran the hospital by opening every day, and hoping.
We were given a second to run through our team, each of us calling out, one by one, what our specialty/training was, like kids calling off numbers for Red Rover. “Internist,” “family practice,” “ICU nurse,” “cardiologist.” It was eery, standing there, listening to this, realizing that no one would ever ask for a license, or ever know that our cardiologist was actually a massively overqualified Stanford cardiologist with a sub-specialty in wilderness medicine. And it wasn't the vascular surgeon who caused the most excitement, but, instead, our occupational therapist. “Can you do wounds and casts?” You could almost see the vibrating excitement as our therapist was sent to the “wound” part of the parking lot.
Sobered, the rest of us divided up and headed to different part of the hospital grounds. Almost every bit of care was conducted outdoors, and I couldn't help wonder what was going to happen when the rainy season started in earnest. The constant screaming of the saws, and flickers of welding were construction workers trying desperately to retrofit the radiology wing before it collapsed in one of the many still on-going aftershocks. It meant that the whole time we were at C.D.T.I., conversations were held at a shout, and problems of translation (English to French to Creole and back again with stumbles due to illiteracy, or culture, or health beliefs) were magnified and distorted. Our ICU nurse and other staff went to round on the permanent mini-city that inhabited the grounds. Kate explained, as though embarrassed, that when patients were discharged, they refused to leave. So the grounds of the hospital were now that an ever-expanding “floor” of patients who never left. Enough of them relapsed, or got new illnesses, that staff were sent to round of them every day.
Our vascular surgeon would finally get a chance to use her surgical skills. No one cared what kind of surgeon she was. She was hustled into the main building, to be shown the facilities, then round on and operate on scheduled patients, and simultaneously be sent patients from the emergency room area with everything from a painful belly to a new massive crush injury. Whether or not she'd ever done, or operated on, any of the types of problems she was asked to deal with, was irrelevant. She was it. If she could cut, they'd have her cutting.
We internists and family practice docs, and our medical student, headed to the packed emergency room area. It was a wide circle of chairs and one table piled with paper and random pills. People milled into the circle, doctors wandered between patients, translators shifted and dodged trying to keep track of both sides of both languages as saws screamed nearby. A random person could easily “beg pardon” their way to slide right between yourself and the patient you were seeing while you were in mid-question. There was absolutely no privacy, and no way to disrobe anyone. Exams were done by sliding a stethoscope now a neck-collar, or leaning against a patient's seated shoulder while you discreetly tried to feel a belly by sliding the flat of your hand down the waistband of trousers. People often came with one or two family members and the family shifted around you, the patient and the translator as you worked, intuitively forming a privacy wall with their bodies, acting as a living, breathing folding screen.
There were no charts, and no medical records. Each patient got a new two page sheet, where you, the doctor, were supposed to write a few words. Impression. Findings. Diagnosis.
Treatment and follow-up were conspicuously missing. And I realized I probably wasn't the only one aware that the whole thing was an exercise in futility. We filled them out, but none of the returning patients ever had any old, prior information. But maybe, hopefully, we were the first wave of providers trying to keep information on what we did. I did notice, however, that these sheets of paper went everywhere when the patient left the area – some lost in radiology, some home with patients, some turned in at a random desk. We learned that if we placed a cast, we wrote on it. In English. The date, the fracture, when it should come off, any information that might help the next person to see that cast.
But every patient who came in with a cast had no information, so the cast had to be immediately cut off. There were no words, no records, no old X-rays, no way of knowing why the cast was there, what was under it, or even, often, how long it had been in place. The assumption was that casts were 5 weeks old (from about the time of the earthquake), but that often proved false. Walls kept falling, and some people didn't get care until weeks after the earthquake or their injury. Even if the casts were actually five weeks old (and presumably ready to come off), people were so malnourished that the fractures weren't healing. And taking off the casts revealed that some people had been inappropriately treated.
One three year old girl, whose twin sister was literally crushed in front of her and her mother's eyes, came in with an odd thigh cast – one that extended to just below the knee. When the cast was cut off, the girl had a baseball-sized lump mid-thigh. You can't know what happened, or under what circumstances she'd been treated (by some desperate provider working in the dark, with a headlamp, by someone running out of cast material who was doing the best they could?), but her upper leg had been snapped in two, then stuck in a useless, too-short cast, and the splintered bone-ends had grown into a fused, side-by-side lump, condemning her forever to have one deformed leg much shorted than the other. We were told there had been no anesthesia, no way to reduce large or complex fractures for weeks after the earthquake, that people were just casted as is to stabilize the bones. You did what you had to do. This girl, with an easily fixable fracture, would now be crippled for life.
But she lived. She was alive. Her mother and father both laughed as the girl wiggled and smiled as our occupational therapist and Kate, the trauma surgeon, gave her a new, neon-pink, hip-long cast.
We saw people wander in with external fixators in place. These are those metal halo-type devices, where metal rods stick out of an arm, or a leg, or fingers. No one had any way of finding, much less contacting, all the people who'd gotten limb-saving external fixators. It's not common knowledge that those metal rods go directly into the bone. Which means bone is, germ-wise, exposed to filth and open air. These patients got no antibiotics, often didn't get told, or understand, when or how the external fixators were supposed to come off. People arrived with seepage around the rods, and puffy infections that went straight to bone. Bone infections, even with the best of Western medicine, are practically incurable. Seepage, fistulas, gradual spreading until amputation – that was the predictable course.
So no one dared to complain about the futility of our little sheets of paper and our haiku-like charting. Standing in the shifting emergency room circle of chairs, people bumping and sliding past, I wrote on my thigh, hunched over - me, the patient and the translator shouting above the scream of the saws. The day heated under the shaded overhang, the wind a hot exhale that brought no relief. I saw a twig-like elderly woman, with regal posture. She had some from a long distance, and this was the first time she'd gotten care since The Day. A wall fell on her, she said, as though this was normal, at aged 73. It took her a long time to dig her way out. She got a big cut on the top of her head where a rock about as big (she pantomimed its size for me) as a basketball hit her. It bled a lot, especially in the long time it took her to dig herself out. It would not heal. She also got a deep cut on her heel, and it wouldn't heal either. But she mostly wanted to show me her arm.
At age 73, her dominant, right upper arm hung at a clearly-broken angle. It had been snapped clean through, dangling at her side for six weeks as she made her way to the hospital. She lifted her arm with her left hand to show it to me, unable to not flinch, and I laid a a palm against her swollen hand, telling her she didn't have to lift it if that made it hurt. But I added that she should show me her head wound. She was beautiful, and vain enough, and dignified enough to not want to show it to me, not in this cattle corral of people. But there was no choice. She had a thick pad of pristine white cloth impossibly balanced on top of her head. This, she lifted off. Then she began to unwind the equally white, lacy scarf that went around and around her head. Underneath it all was her blue-white Q-tip shaped puff of gray hair, the sides carefully braided into a circlet around her head (which a friend or family member must have done for her, given her arm). In her hair was a neat white square of gauze sitting in a deep depression on the very crown of her head. It was as if burying this wound could erase what she'd suffer through, as though there was some shame in her injuries, that no one must know they were there.
I lifted the gauze, and realized, looking at this deep, unhealing ulcer, that she, like the people with external fixators, probably now had an infection so deep, the bones were infected. She, like them, could now be incurable. And, it being her skull, would this infection eventually make its way to her brain? Her heel was just as bad. I stared at these injuries, trying to imagine my grandmother going through such, and I knew in my heart that my Southern grandmother would have also carefully bandaged her wound, neatly wrapped her head with a pretty scarf, and made her way with dignified posture to a hospital. I felt my heart lurch, knowing too much about this woman's possible future and unable to do hardly anything to change its course. I gave her an arm sling, sent her to X-ray, then on to the wound area to have these ulcers scraped clean and dressed, my bitter mind thinking, “a sling, that's what this will all end up being for her, just a sling, after she survived the horrors and finally made it all this way.”
But I consoled myself by thinking you do what you can. And boy, did we - do what we could, that is. Patient after patient, each person's symptoms like a game of name-that-tune, a few notes to go on, an exam, my mind simultaneously whirling between French and English, between what this could be and what I could do, and what was available. I saw a woman whose breast abscess had been sliced open by a previous doc, so deeply her nipple split at the margin. We found a small closet – the only place where you could have any privacy, with a curtain across the front that only came to shoulder-height, the ceiling too low to stand upright in it. I could speak enough French that she and I managed pretty well, with the excellent translator adding nuance, and the sounds of the screaming saw were muffled, as we successfully managed to talk about nursing and mastitis and abscesses, and the need to continue feeding her baby. I realized mid-conversation that I was not just teaching this woman. She was sharp, an advocate and she asked lots of probing questions, many that weren't about her situation, and I discovered she had lots of similar-aged friends (as many moms of babies do), and I took the time to educate her on everything I knew, with warnings about how doctors can often mismanage breastfeeding issues, and exactly what the predictable mistakes were. I, the translator, and this woman were a team as she asked piercing question after piercing question, buttoning her shirt, shifting her baby. It was clear that she already was, or would be the one in her community to teach others, and spread vital health information. Her own misfortune had made her a passionately informed consumer and she was, like so many women and mothers forced into the same position, investing in knowing as much as she could, and sharing it with others. The fact that we stood, hunched, in a dust-coated closet in Haiti while saws shrieked against metal in the distance made no difference. Caring and advocacy are universal.
Families, too, are universal. People came with one or two loved ones. What was striking was how fragile, and defensive family members often were on behalf of their loved one, the patient. It became clear that everyone, absolutely everyone, was suffering from a kind of emotional brittleness. It didn't matter that we had clearly come from a continent away, purely to help – there was a seething, almost palpable fear that maybe you wouldn't help, that you didn't care. It took a while for me to realize that there is probably a distortion of reality that has taken hold in Haiti – that any injury or illness can be dismissed or discounted when compared to the overt horrors that these people have lived through. It is a range of suffering that is hard to conceptualize. I realized, talking to these families, that it is neither strange nor odd, for a family member to feel defensive about bringing her mother to be seen by a doctor for what is clearly a serious medical problem – this mother's legs were getting gradually weaker and weaker until she could no longer stand up from a chair. Feeling defensive and protective, assuming that foreign doctors might not listen, is not odd, not if you've already seen screaming people hacked loose from crushing boulders. You may be believe, before anyone opens their mouth, that these doctors will, of course, pooh-pooh your mother's suffering. Giving of my concern, and care, and empathy became what I did before I even asked what was going on. I realized other team members were doing the same, hands patting shoulder, voices low, hugs given, all before the traditional doctor-role began. Even six weeks after the earthquake, it is as though we were wrapping people in an emotional blanket, giving them a cup of human warmth to warm themselves before we even began to ask the necessary questions.
Besides becoming overtly empathetic, we had become more and more efficient with each day in Haiti and we cranked through the patients. In one morning we saw literally hundreds of people. I found, at C.D.T.I., this weird freedom to giving care here, and for surprising reasons. There were no productivity measures, or 7-minute limits per patient. And sure, there was no threat of malpractice – that might be a bigger relief for some doctors, but since I see patients in America in a homeless clinic, where malpractice is relatively rare, that wasn't a huge factor for me. It was more that I wasn't trapped behind a computer screen, spending more time entering data than I would ever have time to spend with a patient. When you got rid of the American medical documentation – the ever-more-detailed, ever more nonsensically bulleted symptom lists, and the coding, and the billing and all the written or typed out specific disclaimers and the explicit, copied-again instructions, the computer sign ins, sign-offs and the log-offs, the prescriptions, the triplicates, the orders for each encounter - if you get rid of all that - there is a LOT more time to spend actually with the patient, listening, examining, and caring. In only a few hours, by lunch time, our team had entirely cleared hundreds of people out of the emergency room. Not a person was waiting to be seen. Being at C.D.T.I. was a weird, simultaneous reminder of both how vitally important patient recording-keeping is, and how excessively out-of-control we have become with it in America - to the point where your doctor spends literally twice as much time, or more, documenting, than she will ever spend with you. We have long passed the point where that kind of activity is in any way benefiting you, the patient.
I was getting light-headed when I stood up. No one was allowed to drink or eat where you could be seen by patients or their families. It was an act, given the shortages, that could provoke an outburst, or a riot. We were told to go to a break room, a glass-doored rectangular room with a desk at either end, piled high with all our backpacks. The air inside was marginally cooler – just enough to make my sweat chill. Two people were inside, talking, a man and a woman, both looking like they were in their twenties, Americans by accent. I dug in my bag and got a water, feeling my stomach continue to shift and gurgle. But hey, no vomiting so far! I sat down to sip for a few minutes and asked the two, “So, who'd you come here with?” The woman was a nurse, cheerleader blonde, pretty, thin. I expected her to say, maybe, a hospital-sponsored group, or a formal disaster team. Instead, she said, “Oh, I came by myself. Couple of days after the earthquake. Took me a while to find a flight that would take me. Been here ever since.”
My God. Can you imagine it? To leave for the most devastated location on the planet – where there's no security, no government, no way to get help if chaos erupts. To just decide to wake up and go. Alone, blonde, pretty. And determined. I was in awe. And humbled.
Something on my face must have showed, because she said, suddenly embarrassed. “Hey, I've probably got to head back to the States soon. Got to earn some money sometime, right?” She rose, stretched, gathered her stuff and left. To help some more. Like it was just another day.
I talked to the man, a paramedic, for a bit while I sipped. He said, “I'm thinking of heading out into the big tent cities. Some of them, well, no one knows what's going on. They've gotten no medical care, and we keep hearing there are people with massive injuries, and lots of disease. People can't make it into here.”
Would he take security? He tried to not look scornful as he answered, “Nah, there's no one. If you wait for that, those people will never get help.”
I walked out feeling proud of the kind of young people our country produces, so much so that I wanted to weep. In the hall was a man with the tall, square-jawed look of a post-retirement orthopedic surgeon. He was late sixties or early seventies, his hair short and gray, but he was very fit and his biceps bulged as he literally carried the full weight of one end of a stretcher with a paralyzed man lying on it toward radiology. I walked with him on his return back to the ER. Taking a guess, I said, “Surgeon?”
He looked shocked. “No. No way. I'm the lifter.”
He looked, like the blonde woman, a bit embarrassed, his voice gruff. “I wanted to help, so I came. I do the heavy lifting around here.” He whacked me on the back and I nearly staggered. “You got the brains, I got the brawn.”
It wasn't just young people, but people of every age, background and training who left their lives behind to offer help. I watched him walk off. He looked like he should be on a Florida golf course, his collar turned up and his cleated shoes pristine, leaning on a 9-iron. Not here, hauling broken bodies. Hauling and lifting just to do something, anything to help. I found myself blinking against the sun, that lump again in my throat, wishing all the world could know the goodness that has come here to offset, just a bit, the horrors of Haiti.
Doc Gurley is an internist physician and the only Harvard Medical School graduate, ever, to be awarded a Shoney's Ten Step Pin for documented excellence in waitressing. She writes about health at www.docgurley.com, the Chronicle's SFGate, and BlogHer
BlogHer is helping "Write Women Back Into History" by participating in Women's History Month 2010. We are showcasing the stories of women in Haiti in the wake of the January earthquake. You can read more from BlogHer's Women of Haiti series throughout the month.