Reflections of HaitiThursday, Jan 21 Arrival in Jimani, Dominican Republic
There’s no way to prepare yourself emotionally as a human offering to alleviate pain and suffering in the face of a devastating and hopeless crisis, whose magnitude is too large to manage. It cannot be contained and dealt with in such a way as is possible to then “move on”. It is a bloody wound that mocks.
Entering in to this reality – the chaos – of wounded, dying, dead, surviving, grieving, searching – is intimidating. It is arriving on a battlefield seeing the unrelenting power of the victor, Mother Nature. And though the battle was brief, its effects and its fear remain, lingering so that despair is so powerful it enters into your pores, and your every instinct directs you to retreat.
You must conquer yourself first in order to enter in to the aftermath.
Friday, Jan 22 The First Plunge
Ambivalence. Living and feeling extremes simultaneously. Dread and Anticipation. Hunger and Nausea. Plunging in and Stepping back. Appearing or Hiding. Order and Chaos. Known and Unknown. Real or Supposed. Human or Object. Bed number or Person. Personal or Professional. Distant or Intimate. The Individual or The Masses. The wholeness of my body in a foreground of broken, crushed, and amputated patients’ bodies.
Over my head. Haitians speak Creole, a dialect of French that metamorphed as a mixture of French, Spanish, and English languages. The history of the island is bloody and treacherous, and is not forgotten by the Haitians and Dominicans who share the island today. The relation between the two countries is not amicable. The Dominican Republic views Haitians as contaminants to their country, and though the government could not refuse entry to the many wounded Haitians flooding the borders in every possible kind of vehicle – ambulance, SUV, helicopter – it is anxious to remove these undesirables as soon as possible from their midst.
Reluctant, but necessary, was the order given to Dominican public healthcare workers to immunize the hospitalized Haitians whose presence posed a health risk to their country. As the makeshift hospital in Jimani was staffed by volunteers, the majority of whom were American, the language barrier was a significant problem. Speaking Spanish was useful that day. The Dominicans arrived unannounced and began vaccinating patients without rhyme or reason, and without knowing which patients needed which injections. The head doctor on day shift asked for a Spanish-speaking nurse to supervise the administration of the immunizations. I volunteered and by the end of the day I knew the Creole word for injection “pique”, and we, two Dominican healthcare workers and I, had seen all 200+ patients in the four hospital wards to administer tetanus and other immunizations as indicated to the correct patients.
This in-your-face introduction to reality was – is – overwhelmingly difficult. Urgent, evolving needs demanding attention from too few a number of trained hands with the ability to give it. Faces swirling in and out of my mind – their pelvic fractures, their bandaged stumps, their limbs stabilized with hardware sticking sometimes almost three inches out of their skin in all directions, the women tending to their babies, the women whose exhausted bodies were working hard to protect the baby growing inside them, the men grieving the loss of limb and future livelihood, the resilience of children who cannot comprehend their future – the comprehensive reality of an entire country.
Tremors, “aftershocks”, are apparently common after large earthquakes, as tectonic plates flex their muscles and settle definitively into new position in the earth’s crust. The trauma of any natural disaster causes acute stress in the people affected; and even more so when the disaster is a large scale earthquake with continued aftershocks. Those whose homes were not destroyed now stand abandoned, as their former inhabitants take to sleeping outside in the streets just in case another earthquake should happen. No one wants to be caught under the rubble this time.
At around 7:00p.m. I felt two tremors. They were weak and no cause for alarm, insignificant to the untraumatized mind. But for the patients, there was instant panic. The facility we were using as a hospital was actually built to be an orphanage, a two story structure with several large rooms. The hospital was divided into four wards. There were so many patients in each room that some spilled out into the halls. Patients who could walk ran out of the hospital, while patients who were immobile dragged themselves out as best they could. Family members pulled patients out on their mattresses into the grass away from the building, and one desperate man jumped from the second story to get out of the building. The crack that was heard when he hit the ground was his spinal column breaking.
Chaos and fear. Pandemonium. Locating patients. Matching up charts. Assessing new injuries. Bringing a semblance of order to disorder. Quieting the chaos, calming the fear, soothing pain and discomfort, waiting for adrenaline to pass and sleep to take over the night.
Saturday, Jan 23 Day Shift in Ward D
Morning came abruptly. Having packed a sleeping bag, but no tent, I chose to pass the night in the rental vehicle. Scrubs double as great sleepwear, so getting ready was easy. The only oddity is entering into public without having had a look in the mirror first.
The crisp air does much to awaken the mind, just as the peace of sunrise brings hope and prompts compassion in the heart for the work to be done in the day ahead. I was anxious, but ready for the day.
8:00a.m. and it was already getting hot. We soon realized that the patients had no intention of returning inside the building, as we watched family members use whatever they could find – sticks, broken cinder blocks, rocks, bed sheets, plastic tarps – to erect crude tents to shade their loved one from the sun. We passed around sun block.
Ward D had about fifty patients, with only four nurses to care for them. Access to patients was a challenge, as patients shared tent “walls” and privatized their new living space. Just making sure that each patient had received his antibiotic and pain medication was difficult and time-consuming, let alone assessing vital signs, maintaining IV fluids, giving IV meds, and changing wound dressings. And charting. Charting was several scraps of paper with operative notes by surgeons in the OR, illegible handwriting by whatever doctor did rounds the previous morning and evening, and the conspicuous absence of standing orders and nursing interventions. Figuring out when the last time pain medication was administered to the patient was impossible, as many volunteer health professionals apparently considered charting an optional activity in this less-than-optimal environment.
By mid-morning, with sunburned necks and sore backs from bending down, leaning over, and squatting by patients whose mattresses were lying directly on the ground, an engineer pronounced the building structurally sound and the head day shift doctor announced that we should assist patients back into the building.
By this time many patients were sweltering in the heat and agreed to go back inside. Ward D was seven rooms in a row with an outside corridor at the top of a slight embankment. The patients were about twenty yards away. We began to move the willing patients by picking them up by their flimsy mattresses – this took four to six people – and walking slowly up the slight hill to the corridor and inside. The most painful transits were the patients with external fixators (screws, pins, and other hardware) holding their bone fragments together. After about four hours, a fourth of Ward D patients were no longer lying in the sun.
A beautiful thing about nursing care is that the very nature of it creates an instant intimate relationship between patient and nurse. In Room 7 of Ward D in bed 8, Jaune lay flat on her mattress on the floor with a tibial-fibular fracture to her right leg. She needed a dressing change, and it was going to hurt. External fixation – being able to screw bone fragments together for stabilization – means a much higher likelihood of correct healing. At the same time, it also means that care must be given to keep the hardware clean and dry for the next 8 weeks to avoid infection that has a direct pathway to the bone.
One of the most painful realities looking at a roomful of patients was seeing some patients with external fixation and other patients with amputations. It all had to do with timing. One might think that the first patients brought to the hospital would be at an advantage to the ones who spent more time under the rubble and were pulled out later. Not so. In the first few days following the earthquake, there were no supplies – no anesthesia, no pain medication, no hardware for external fixation. Amputation was the only treatment option. Those patients who came to the hospital a week later found ample volunteers, supplies, and hardware. Their limbs were saved.
And so it was with Jaune. As I cut through the dressing as gently as I could, I could see Jaune wincing. With the dressing off, I could see the ten inch incision they had made and stitched together again, and a huge chunk of missing tissue along the back of her leg. It looked like perhaps her leg had been pinned under rubble and as she was pulled free an 8 inch strip of calf muscle had gotten ripped off. Despite Jaune’s discomfort, she never cried out or asked me to stop. She resolutely accepted what had to be done. After washing and applying triple antibiotic ointment to the wound and pins sticking out of her leg, Jaune helped raise her leg as I wrapped the final dressing around it. As I gathered all my supplies and stood up, Jaune blew me a kiss. This is the people of Haiti. Strong, resilient, beautiful, thankful.
As the sun went down, the patients indoors began to relocate, yet again, outside. Aftershocks, they believed, happened at night.
Sunday, Jan 24 Floating, Finding, Filling
Sleep in a bed was good. There were a few rooms on the second floor, above the OR, and two beds became available for the three of us. Pushed together, three girls in sleeping bags can sleep great. We checked the schedule posted on the wall, expecting to work the day shift again, but we were not assigned for day shift or night shift. Since we knew that there were too many patients and not enough nurses, we decided to “float” and help with patient care again.
One might expect to find a patient in the morning in the same place that you saw them last night, but that assumption would be wrong. The patients were still constantly migrating. The hospital was no longer trying to move patients indoors. The outside areas were now delineated by two rolls of gauze bandages across the grass, creating three, no longer four, hospital wards. Many of the patients, especially the amputees, needed special wound care, under anesthesia. A minor procedures room was set up next to the pharmacy, and patients were taken to the room for debridement (cleaning and removal of dead tissue.)
Locating patients to take to the minor procedures room was a challenge, because patients were no longer in Ward X, Room Y, Bed Z. Finding a patient was like tracking a nomad – they were always moving – outdoors, indoors, hallway, etc – and hard to keep up with. As an “extra” for the day, I offered to take a patient census of Ward C so that patients on our ward could be found more quickly. Without a way to reference patient location by room and bed number, I used landmarks such as the barbed wire fence that ran along one side of the ward, and the gauze roll on the other side that distinguished our patients from those in Ward B. I also made a diagram of the ward and numbered the beds to match with a numbered list of patient names. As long as the bed was tracked and updated on the sheet, we would not lose track of a patient on our ward.
The day went on and as darkness set in, we lost electricity. I suppose that my head light is the reason I was approached and asked to locate a patient for discharge to another hospital. Thanks to the census, we found her quickly. She was a young mother with a possible pelvic fracture who had been separated from her baby when she was brought to Jimani and the baby was sent on to Santo Domingo. As I reviewed her chart, I could not find any standing orders for pain medication or an antibiotic regimen. Rather than track down a doctor in the dark, I prescribed both antibiotics and pain medication, filled the meds at the pharmacy, gave her discharge instructions, and dosed her heavily on pain medication for the six hour car ride she would endure to arrive at the capital to reunite with her baby.
Night shift is usually not nearly as busy as day shift. Sleep is one of the most important factors in healing, as growth and repair of body systems is more efficient during sleep. By 10:00p.m., all patients had received pain medication but not all had eaten dinner. An increasing number of patients and family members, and an increasing number of strangers pretending to be family members, were all receiving food three times a day. As more desperate people loitered around the hospital to get free food, the food ran out before all patients were fed.
One of the things that had frustrated me the most over the weekend was the lack of consistent charting. So when the floor was given a real progress sheet in the evening for each patient chart, I was ecstatic. I couldn’t hide my enthusiasm and proceeded to transcribe the standing orders, medications, and procedures for each one of our patients. By the time that was done, it was nearly 11:00p.m. and the kitchen crew had finally returned with plates of food for those patients who had been waiting to eat since 7:00p.m.
The last contribution we made to the evening was trash detail. Having packed trash bags along with my stethoscope, otoscope, thermometer, and gloves, we moved along the entire “camp” and picked up the empty Styrofoam plates, water bottles, and miscellaneous trash that accumulated to overflowing every few hours. Another day was done.
Monday, Jan 25 Stepping Up
Another tremor, after midnight. Pretty strong. We were awake in bed, and heard many people run out of the building. You could hear the walls shaking, and feel the power underneath, above, and around you. I wondered what the tremor must feel like in Port-au-Prince, and said a prayer for calm for the patients trying to sleep in the field outside the hospital. Very soon after, I went to sleep.
In the morning, we contacted a missionary who was going into PAP each day, distributing food through trusted church leaders. These same churches wished to open their doors to the “walking wounded” who needed medical treatment. We stepped up to gather all the medications that we would need from the overflow of medication donations in the hospital pharmacy. Finding the medications, estimating the amounts needed, packing them in a way so as to access easily, and creating a formulary was our mission for the day.
When you’re in the hospital taking care of patients all day long, you don’t have much time to process what you see and feel. But today, grabbing medications off the shelf, I found myself asking, “What exactly are the rules, God?”
It seems we have been left to our own destruction. What is fair about the aftermath of natural disasters? Jesus came to earth and conquered death. Those who receive Him live forever with Him in a new body. God made certain rules, set certain limits – the age of man shall be 120 years (Genesis 6:3.) What about the young lives taken by the concrete and the rubble?
Why are some lives easy, soft, to excess? Why are some hard, insufferable? God made us in His image. When man began building the Tower of Babel, God destroyed it, saying “Nothing will be impossible for them.” (Genesis 11:6). He confused man with languages to limit his power.
Perhaps He saw we were not using the power He had given us for good. Perhaps God learned his lesson previously, chose to intervene and limit His creation so that humanity would not become another Satan. We have been put in our place for our own good.
All things are not yet under God’s submission (Eph 1:10). When will that day come? We pray for God to act after the disaster. And we expect Him to and believe He is. But why do we believe, are content to believe, that God will act after, but not before tragedy, and certainly not without petitions.
I want to know that God is my Pursuer, watching out for me, and keeping me safe in this world. So, God, What are the rules again?
Tuesday, Jan 26 The Walking Wounded
Crossing the border into Haiti turned out to be a piece of cake. Slap a Red Cross insignia on your windshield and you don’t even have to stop. Entering Haiti was a little eerie. Everything was covered with a thick layer of dust and piles of rubble were everywhere. It was hard to know whether the damage we observed was old or new. Signs tacked on to posts or buildings in Creole, French, Spanish, and English advertised the desperation of the people, “We need help” and “Need food and water”. We noticed a long line of people along a sidewalk and U.S. soldiers patrolling the crowd as we neared the U.S. embassy. One the other side of the street our driver pointed out the collapsed U.N. building.
We parked in the street in front of a small church where many people were already waiting for the “clinic” to open. We worked steadily with the assistance of translators. The patients with severe wounds were shunted to one station manned by an orthopedic surgeon who had been at Jimani hospital earlier in the week. We received the rest of the patients, whose maladies ran the gamut of respiratory infections (due to the dust and rubble) to proximity-related diseases (skin and GI infections due to the crowded living conditions in the “tent cities” where the majority of people in PAP were now living without water or sanitation.)
Every single patient we saw was suffering from acute stress, commonly complaining of neck and back pain, headache, anxiety, insomnia, nightmares, panic, grief, and hopelessness. We were all very aware of how inadequate our pill box was, and I soon changed tactics after prescribing several patients a sleep aid and feeling lousy about it. The context was highly appropriate for anxiety, and as a matter of personal safety patients probably did not need to be able to sleep through the next big bang, with no security for their personal belongings and looters out on the streets taking what they wanted for their own. Prayer became my medical offering to each patient, and to my surprise, was eagerly and gratefully received.
Again, it was difficult to enter in voluntarily to the grief of each patient. The most heart wrenching for me were the elderly, who recounted the loss of children and grandchildren in terms of numbers, and could not hide the fear of the knowledge that the only people in their life obliged to care for them were gone. What would become of them?
Wednesday, Jan 27 Dawn of Day
Six days of deprivation of familiarity, comfort, loved ones, and common experience. Not long after sunrise Cameron and Kurt arrived with more medications for the hospital and other clinics. There was comfort in hugging people anchored to “home.”
We set out for the day with an actual agenda. After leaving medications at the hospital, our next stop was en route to PAP, at a Christian outreach clinic and small hospital that had no anesthesia or pain medication for the deluge of patients still flooding the compound fifteen days post-earthquake.
With nearly all health centers in PAP destroyed, health care for even the simplest conditions – a child’s ear infection, the labor and delivery of a baby, an asthma attack – became complicated. There was just nowhere to go. With this in mind, we returned to the church clinic at which we worked the day before.
When we arrived the surgeon called us his angels and we got right to work. I had a new translator, a beautiful twenty-year-old who was a member of the church. She and I got into a rhythm and I was so grateful for her. Towards the end of the afternoon, a young woman came in with a seven month old baby girl. As I asked questions, a sad story unfolded. The young woman holding the baby was not the mother, but a cousin of the mother. When I asked why the mother wasn’t there, the cousin replied that the mother had tried to kill the baby, so she took her. She was concerned that the baby couldn’t roll over yet.
The baby was obviously underweight, but until I took the baby in my arms I didn’t realize the severity of malnutrition – the baby had to be less than 7 pounds and was getting only two bottles a day. A quick assessment of her heart and lungs revealed pneumonia, and a fever of 103°F. We dosed the baby with Tylenol, and prepared a bottle of formula. Meanwhile I mixed a wide spectrum antibiotic for injection, and grabbed more cans of formula, some diaper rash ointment, Tylenol, and oral antibiotics. After giving the injection, and explaining the baby’s need to feed every two hours, we carefully wrote the directions for each medication, and emphasized using only clean boiled water for the baby’s bottle. To sum it all up, “lots of bottles, and lots of wet diapers” is a good thing.
Thursday, Jan 28 Decompression
We stayed the night in PAP. At about five in the morning there was another tremor. Each aftershock is a cruel and visceral reminder to victims that renews the vivid memory only the passage of time can fade.
The world is unraveled. It is a fabric coming undone exponentially. These unraveled threads – split fragments – have lost the inherent strength of the whole. It is beautiful to see fragments knit themselves back together for a time – disaster relief from all over the world – Spain, Japan, states all over the U.S., Canada, World Vision, IMA – yet it will hold only for a short time, not having really “mended” the rent in the fabric. We can tolerate proximity only for so long before the threads choose independence again. Threads are weak.
God, where are you when the earth trembles?
-On My throne. (Psalm 47:8)
God, get down here, it’s a mess.
-I did. It is finished (John 19:30).
Where is God now? In His people, the church. The only place you will find God is in His people, the body of Christ. In nature, at times you find an imprint of God, at times you find the horrors of natural disasters. But in His man, you find God Himself. That is the only place you will find God today. The body is His temple; that is where He will be found. I am His woman; God may be found in me.
Friday, Jan 29 Departure
God is seeking those who are not yet His. How does God seek people who are not yet His? – exclusively through the people who are already His, I believe. We live in end times. All I can say is, “God Come Quickly.” (Psalm 70) Shouldn’t we plead with God for His Second Coming?
How do you live your own life intentionally and conscientiously when you were given ease in the face of so much difficulty, wealth in the midst of poverty, opportunity in the midst of none?
Because you know, Go.
“Here am I. Send me.” (Isaiah 6:8)
When Haitians pray, “God, Come Quickly”, they mean you and me.
So be it.