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Photos from Haiti. Barry J. Knapp, MD, FACEP went to Port Au Prince, Haiti with the Virginia DMAT Team January 25 - February 1.
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The Mission of Hope, Haiti
Letters from James R. Dudley, MD, MBA, FACEP
We learned James was headed to Haiti on March 1. Here are the letters he wrote about this unique experience during his week at the Mission of Hope, as a member of Team 7.
March 1, 2010
I have gotten hooked up to go on a mission trip to Haiti, through an orthopedist from Texas and his wife, Joel and Ashley Hurt. She is the lead coordinator and lead contact person and she has offered to include my friends on their daily reports from there. We leave on Saturday, the 6th. Returning the 14th. If I have time and connectivity, I will send you my own reports, but I can not promise anything.
James Dudley
March 1, 2010
As you know, there is still tremendous need in Haiti. This Saturday, March 6th, a team of doctors, nurse, and medics are going to a town about 15 miles from Port au Prince.
The team needs several more nurses and a couple of medics for that week. If anyone on your team is able to go on short notice, please have them contact Ashley Hurt at the address above. Ashley can send information about what is needed for your team member to go.
Gwen Harry, If you would kindly forward this message or cut and paste the appropriate parts of this message to all the ED Directors in VA, perhaps they know some nurses who are available. Likewise, if you know the current VA ENA contact, that would be great, too.
If anyone has any questions, please contact me. Thank you all for spreading the word!
James Dudley
March 7, 2010
Greetings from sunny and warm Haiti! Several of you have expressed an interest in hearing about our work here, and my hope is to send updates as time and technology permits.
Our team has been brought together through the tireless efforts of Ashley Hurt and many others from her church in Austin,Texas, as well as Jennifer and Alicia of Texas Orthopedics. They are supporting an organization called Mission of Hope-Haiti (mohhaiti.org), which is north of Port au Prince, in a place called Titanyen.
On our team are Nurses, Paramedics, an Anesthesiologist, two Orthopedic Surgeons, two ED physicians, as well as a Nurse Practitioner. We even have a Plastic Surgeon and a Mental Health professional. All together, we number close to 20.
The Orthopedist on our team, Dr. Glenn Spiegler practices at Riverside Tappahannock Hospital in Tappahannock, Virginia and someone called him about 10 days ago and asked if he was interested. (He is not sure, but it may have been Dr. Joel Hurt, a fellow Orthopedist, and husband of Ashley Hurt). Glenn called me and I passed the word on to Beth Bortz at the MSV Foundation. Our Nurse Practitioner came through that connection. I called one of my EMS colleagues and she, too, was able to join the group. The power of our 'Contacts' list on our email address books is just remarkable and we have folks from Canada, Texas, Oregon, England, and Virginia.
So, most of us are arriving today in Port au Prince and traveling to the Mission of Hope compound where we will stay. Today, we have tried to get oriented, organized, and ready for tomorrow, when our real work was supposed to begin. Unfortunately, just as we were finishing our inventory of supplies a young man was brought, sweaty, pale, and clammy. His family brought his medications; a small Walmart bag with five cardiac meds. He had undergone cardiac surgery in Indiana a year ago and was fragile even before he became ill yesterday with a fever, diarrhea and abdominal pain. He was critically ill, probably with sepsis. He required vigorous resuscitation, including a central line and intubation, as well as transfer to the field hospital near the airport that has been set up by the University of Miami. There they have ventilators and Intensive Care Units, all in tents.
If anyone is looking for an adventure, ride in the back of an ambulance, lights and sirens blasting, through the unlit streets of Port au Prince at night, crowded with tens of thousands of people on foot and bicycles.
So our real, real work starts in the morning.
James Dudley
March 8, 2010
Hello from Titanyen, Haiti! It was a beautiful day here, warm but breezy. It feels tropical and the pace of life seems like what one would expect in the islands.
As many know, the length day in the tropics doesn't vary much with the seasons, and so sun-up is a few minutes after 6 in the morning, and sunset 12 hours later. Haiti is very mountainous and our compound is situated on the southwestern slopes of a mountain range, so the sunrise is delayed just a few minutes more. Most people in the area where we are seem to rise and set with the sun. Last night was breezy and quite comfortable and it was easy to get going this morning. After rounds on the 6 orthopedic patients in the hospital, we walked up the hill to the clinic. It was about 8:30 and there were at least two hundred people in the queue, some with minor issues, some more serious.
We met Dr. Jennifer and later Dr. Alix, our Haitian hosts who staff the clinic on a regular basis and to whom we could run anytime when we had questions about local practices and more importantly, the spectrum of disease we were facing.
We worked as fast as we could to take care of all the patients, sort out the really sick from the not so sick, the acutely ill from the chronically ill, or malnourished. The range of needs, medical and social and spiritual was significant; challenging and exciting. In some ways, I felt like a medical student on the first day in the wards.
Almost without warning, the mad rush was over. I went to find Dr. Jennifer, my new-found mentor, but she had gone. Early in the morning, she and I had talked about Wigans, the young man we had worked on feverishly just wee hours earlier. Dr. Jennifer had been his primary doctor for the last two years and she had made huge efforts to care for him, even traveling to Cuba to arrange medical care for him, and staying with him at Christmas last year, acting as physician and mother for him during another hospitalization. His death overnight hit her especially hard, as it did many of those who work in the clinic. They all knew Wigans and knew the struggles that had been made for him.
This evening, as grace was said before dinner, a prayer was made to bring healing to those suffering in the wake of his passing. It helped ease the pain, as did the wonderful music after dinner. There are two groups of college students here, about two dozen in all, and they provided a beautiful chorus for the pastor who played the guitar and sang with clear rich tenor. A good night's rest will bring a renewal of energy for the work tomorrow.
All are well here and send their love and greetings to family and friends back home.
Goodnight,
James
March 9, 2010
Good evening from the Mission of Hope. The crickets are chirping the team to sleep in their respective bunks and tents, as things wind down on Tuesday evening. The evening after dinner brought lots of pleasant conversation and excitement about the work done today and the challenges facing us tomorrow.
One of the highlights today was the work of the orthopedists. The team did a very difficult repair of an unstable fracture of the tibial plateau - the broad top of the shin bone. The fracture had been set at the time of the earthquake but was still unstable even though some bone repair had started. They were able to put the fragments back in good position, using a plate and screws to stabilize everything. The patient has an excellent chance of regaining full use of his leg.
Each morning, there is a long line winding its way up the hill to the clinic. By the time the gates open, many have already been in the queue for several hours. Our Paramedics triage the sickest to go to our small 3-bed Emergency Room for giving IV fluids, and monitoring. Three other doctors and their translators work steadily to see the many others Meanwhile, our Physical Therapist stays very busy, between therapy sessions with the orthopedic patients on the hospital ward, and wound care in the clinic. One of the interesting cultural aspects we have noticed is that when a Haitian undergoes surgery or a serious injury, it is common for them to stay in bed, waiting to get well. It requires significant education and encouragement to convince them of the benefit of early and sustained mobilization following surgery. Even in the few days on site, we are seeing them make gains from those efforts.
Today's musical moments were varied and mostly spontaneous. Anyone, anywhere is liable to break into song, and although the words are in Creole, the hopefulness conveys in a universal language. And when one starts, others join in. The Haitians seem to express themselves in song as easily as in conversation; the singing starts early in the morning, on rounds in the wards and in the waiting area outside the clinic, and goes well into the evening.
Around sundown today, the large open-walled church was full of worshipers, singing full force, sending echoes several hundred yards up the hill to the hospital wards. There, patients and their families, who stay with those hospitalized to feed and help care for them, heard the singing. Within a few notes of hearing each new song, they have joined the chorus. And it feels like real healing is taking place.
Goodnight,
James
March 10, 2010
It is nearly midnight, and the camp-style singing, tonight a gift of our college colleagues, continued until nearly 10. I don't know if the guitar lives here, awaiting the next player, or if one of the others brought it. It definitely seems that college aged men and women definitely have more energy this time of day compared to some of us middle aged doctors and nurses. They have probably done a lot more hard physical work today than we doctors and nurses, but most of our group has turned in while many of them are still giggly. Ah, to be so carefree.
Mission of Hope-Haiti lies above the northern shore of a large horse-shoe shaped bay that is also ringed by mountains on the south, and east. The opening of the bay faces west, and the south eastern edge of Cuba lies fewer than a hundred miles away. The Mission property sits on the foothills, no more than a few miles from shore, probably about five hundred feet above sea level. Its views of the Caribbean are spectacular. The 70 acres are basically a large narrow rectangular of land with the long borders running more or less in a south to north direction, up the hillsides.
The gates of the compound are at the downhill, southern edge, and it is there, at the gates, where the queue forms each morning. The Guest House, where we stay, lies well up the hillside, probably a half mile up from the gates. The rocky road winds up the eastern side of the property. As one travels north, up from the gates, the large church, which holds hundreds of worshipers, sits to the left, or west. It has a large low-pitched A-framed roof and only posts hold up the roof and its trusses; its walls are open.
Beyond the church is the cafeteria for the schools and to its west, a substantial concrete two-story rectangular High School. Each floor has a long central hall with classrooms on each side. After the earthquake, the school was needed for medical purposes and now it houses a hospital ward. There, our nurses, two at a time, around the clock, staff the downstairs ward, where patients are arranged up to four in a room. Family members stay with each patient. Tons of supplies are packed into the upstairs classrooms, but these temporary quarters have to find a new home soon, since the Haitian government expects school to reopen in April. In one of the store rooms is a box labeled "Tents for discharged patients".
A hundred yards up the hill from the ward is the Clinic, and as the doctors and the day shift nurses walk down for rounds and change of shift in the morning, the gates open and several hundred people of all ages, a few at a time, wind their way up the hill. It is a sight to behold, a quarter mile line of people, hurrying as best they can to be the first in line.
The Operating Room team heads directly to the clinic, and finishes their last minute preparations. As the patients gather outside the clinic one of the nurses greets those assembled and matter-of-factly leads them in song. This morning's hymn was a beautiful Creole version of "Praise God from Whom All Blessings Flow". The conviction the Haitians expressed as they embraced the message in those words left me shaky. Following the hymn was a prayer. The rhythm seemed vaguely familiar as the phrases, some long, others shorter, rolled into the clinic from the waiting area, but its Creole words were lost on my untrained ear. The nurse told me later it was the 23rd Psalm, about walking through the valley of death.
We have no time to dwell on those moments as the pace of the day's work overtakes us. Each person has a story to tell, or a hundred stories, and we each gather bits and pieces as we do our respective work. The team comes together a little more smoothly each day. The medics transport patients up from the ward to Pre-Op, then triage the masses. The ER fills and treatments begin on the sickest of the group. The exam rooms fill and we move as many as we can as fast as we can, trying not to miss those who are truly acutely sick, and not simply exhausted, hungry, burdened by parasites or lingering grief.
Then, as before, almost suddenly, they are gone except for the late OR cases, and those awakening from surgery. In some ways, we all struggle to regain our bearings.
So, at the end of the day, to share food and stories and music, brings peace and closure and allows us to drift off without worry.
Goodnight to all back home.
James
March 11, 2010
Hello again! Just as I hit 'send' last night, our team found out what it is like to have the only 24/7 hospital in this area of 'Ayiti'. An important security official from a nearby town showed up with several armed escorts at the compound's front gate, requesting entrance; he was suffering terribly from a "belly ache, belly ache, fever, terrible fever". The guards radioed up to the ward where Dave, the flight medic, and Amie, our nurse practitioner were on duty, passing on their request. They talked it over, (well, maybe for about 15 seconds!), and soon, they were evaluating the gentleman. The call came up to the Guest House a few minutes later; orders were given and treatments started, and in a few minutes, as the 'on-call' doctor, I was on my way down to the ward.
At night, the local populations of ponies seem to graze more freely, closer to the roadside than during the day. But, they remain skittish. Even though I expect them to move away as I approach, when they finally do bolt, I can't help but feel my heart race. I couldn't help feeling a kid's sense of grand adventure, as I made my way down the hill. The stars to the south were spectacular with constellations we from the north rarely get to enjoy.
I had asked Dave to place our newest charge away from the other patients, partly out of deference to his status in the community and partly out of concern that should he be contagious, it wouldn't compromise the other patients, most of whom are post-operative patients. The Mission of Hope Hospital has one of the cleanest Operating Rooms on this side of the country, and it has allowed our pair of Orthopedic Surgeons and our Plastic Surgeon to take on very complex, professionally satisfying, and meaningful work. They are giving significantly injured patients a wonderful chance to return to normal or near normal function, but it is essential that we be vigilant to prevent wound infections. Dave and Amie had come up with the perfect solution. The officer was appropriately placed at the far end of the ward's central hallway, away from the others, on a mattress with fresh linens. Along with the IV fluids and medications he had received, they had also done the hard work of reassuring him and his wife as well as his comrades. Our able, if sleepy, translator, along with the patient's high level of education and ability to give precise details about his illness made my job easy. We decided to allow him to rest in his relative privacy until one of our Haitian physician colleagues, Dr. Alix, could weigh in on the situation in the morning.
The waning crescent moon was just rising over the mountains as I made my way back toward the Guest House around 2 AM. However, another patient, a 5 year old trauma patient, came in around 5 AM. He was on a small motorcycle with his dad and another young man, headed to the clinic to have a rash on his hands evaluated when his bare foot slammed into a cinder block wall. A large cut on the inside of his ankle was just the tip of the iceberg. Again, Amie and Dave did all the right things. The IV Morphine eased his pain, and the first dose of IV antibiotics began infusing within an hour of his injury. They reported he never whimpered as the line was started.
On the way down to check on him, as I rounded a curve and emerged from a clump of trees, I saw a small figure sitting on a boulder playing what looked like the guitar from a few nights earlier. Jean Marc, about 14-16 years old, sat facing east as the sun rose from behind the hills and lighted his face. There was no one within a hundred yards of him. Jean Marc is the daytime translator for us on the wards, and his shift hadn't yet started. We chatted as he strummed away and after a bit, I asked him if he sang or just played. "Oh, yes, I like to sing", and added his warm voice to the easy rhythm of the chords.
The antibiotics were finished by the time I made it to the ward.
The boy with the injured ankle required not only orthopedic work, but the transfer of a nerve by Dr. Matt, our Plastic Surgeon. This nerve is to take the place of the nerve on the inside of the ankle that was avulsed by the wall. Without this nerve, sensation in the foot is lost, and in the harsh environment of Haiti, inevitably he would end up an amputee, probably after years of progressive disability. The whole team is really coming together to make a difference here.
As we share stories at day' s end, one concern we all have is who is going to step into our respective places once we leave. The need is not just now, it will be for years. Mission of Hope is working, as are many groups, to build this as a sustainable venture. This is the essence of the work we were all called to do when we set out on our careers. For any who are able, this is an opportunity of a lifetime.
Goodnight,
Love to all back home,
James
March 14, 2010, 00:54
Our brief visit draws to a close. Most of us just landed in Miami, tired, excited, our heads spinning.
A handful of our nurses (Hannah, Sally, Agnes, and Lyn) are staying for a second week, so they will mind the patients in the ward today and through the night. Along with Brad, Grant, Lindsey, Dr. Cheryl and the rest of our new-found Haitian and Mission of Hope friends, a smooth and coordinated hand off of our patients to Team 8 is assured. At least we won't fear for the well-being of that group of patients. They are in good hands at the Mission and will get the care they need. In fact, Dr. Glenn just told me that he gave report by phone on all the recovering cases to the oncoming Orthopedic Surgeon.
For our last full day on Friday, as with Thursday, the sun peeked over the hills across a nearly cloudless sky, and by 9 or 10 the heat was building. We had to remind ourselves to drink lots and lots of fluids, and even then, it was hard to keep up. The Team worked hard, with several very ill patients early in the day that made us a little slower than normal treating the more routine people. We had to transfer a young feverish man to a hospital over an hour away. He was most likely suffering from cerebral malaria. Another woman we sent to the local Obstetrics clinic. She was nearly due, had minimal, if any, prenatal care, and was having contractions. We were worried about her being in premature labor, complicated by severe anemia. We needed a bed for another elderly lady with congestive heart failure, whose lungs were half full of fluid from chronic untreated hypertension, but she wasn't too uncomfortable sitting up in a chair, so that is where she stayed for treatment. We parked her next to the bathroom after a large dose of diuretics. Thankfully, several visiting nurses from Wisconsin arrived and offered to help (I have no idea who they were but I do know they dropped in at just the right time, proverbial manna from heaven). One was kind enough to provide one-on-one care for several hours as the lady very slowly improved.
Yesterday was our busiest OR day yet, and we ended the busiest operative week to date for the Mission. As a testament to the maturing capabilities at the Mission, most of the work is being referred from other hospitals in the surrounding area, including the University of Miami tent hospital in Port au Prince. Accordingly, the wards were filled with patients their families, translators, many of whom were operated on earlier in the week. One of our nurses, nurse Julie, gave her tent to one family to go away with. At least then they would have a home to take 'home' as they left, a shelter in which to care for their special needs child.
When Team 8 arrives, the members of the their team will need to look over as much of their work and supply areas as possible to quickly get an idea of what they have and where things are. When the doors open Monday morning, things will ramp up quickly! We are excited for them, for we know they will continue to provide much needed care. We now know, as prior teams have learned, and as future volunteers will as well, that we have received far more from the Haitians than they have from us. We know that the next team will come home wanting to go back. They will be reminded of how good it feels to bring together a large group of individuals, each with his or her own skills and gifts, for a common purpose, each one willing to focus only on the mission, the goal of helping just a few people who need our help. They will be reminded of how inspirational it is to be led by those who live their faith.
And they will come home with hundreds of stories. Stories of horror and tragedy and struggle. And songs. So many songs. And they will see faith and resiliency and hope and love. In action. They will feel it and see it and smell it. And they, like us, will never forget, and will be forever grateful for being allowed to be part of this.
Dr. Glenn and I were talking a few minutes ago, still trying to grasp the scale of it all. This afternoon, we drove for several hours through the streets of Port au Prince, a city of between 3 and 4 million people before January 12th, trying to make sense of whether our tiny efforts mattered.
We remembered that we only saw 500 or so in the Clinic this week only operated on about 30. Could this really amount to anything given the scale of the need? In the face of such obstacles? When what is needed is not just 21st century medical miracles eked out one at a time, but shelter, food, clean water, education, and opportunity?
The answer is absolutely yes. If we do our part, and other teams do their parts, and the efforts continue, then after a year, 1500 will have had surgery, and twenty-five thousand seen, just in the Mission of Hope clinic. If 20 other missions and NGO's do what the Mission of Hope is doing, then after a year, 30,000 Haitians will have had surgery and half a million seen in the clinics. Together, each doing a little, we will have made a difference.
Now is a good time to look at the calendar, and pick a week, and join this effort. Put your gifts into action. We are grateful we have, and look forward to having others join us when we return.
Goodnight from Miami, and goodbye from Team 7
James
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