Guest Editorial: Medical care still needed in Haiti | Columnists | Summerville Journal Scene

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Guest Editorial: Medical care still needed in Haiti

Published Thursday, March 04, 2010 11:37 AM

By Ed West, MD
Summerville Journal Scene ®

Editor’s note: Dr. Ed West is a Summerville resident and doctor, affiliated with both Summerville Medical Center and Trident Medical Center.

“I returned yesterday evening from an eight-day journey to Port-au-Prince where I served as a physician on Medical Team 2, one of four small, mobile medical groups organized by the SC Baptist Disaster Relief leadership in response to the earthquake.

Local travel was restricted and communications even at the leadership level seemed fragmentary.

We left for Haiti as a group of seven - two nurses, one licensed clinical counselor, one logistics specialist and two pediatricians - under the supervision of our team leader, an EMT.

Most of us had received training in the SC Baptist Disaster Relief program and most of us had prior experience in third world medical practice. I do not know to what extent the organization of Team 2 was typical.

We were joined in-country by two additional nurses who were also trained in disaster relief and had been members of the medical team which we relieved. They provided continuity of care.

International Travel

The team assembled in Columbia, arriving by private arrangements. A volunteer drove us to the airport from the “Baptist Building.” We were all wearing our distinctive shirts which probably helped us to pass airport security with our ponderous and somewhat suspicious baggage full of drugs and odd-looking equipment with wires and batteries. We departed Philadelphia as a snowstorm arrived and arrived after 10 p.m. in Santo Domingo, DR.

A newly arrived medical team from Alabama greeted us in the airport and the local IMB missionary met us and escorted us by bus to the mission compound in the city. We rested for a few hours on mattresses on the floor then waited in the dark for bus transportation. The bus to the Haitian border was air conditioned. We felt safe in DR and were not molested at the border. Soon after we crossed into Haiti we stopped at a pre-arranged site and met the debarking Team 1.

The doctors had only a few minutes of conversation with the physician of Team 1 before the two groups proceeded in their opposite directions. The day long trip across Hispaniola was fatiguing but not as white-knuckle dangerous as third world travel can be.

Accommodations

The Florida Baptist Convention has constructed an enclosed mission compound in a relatively affluent suburb of Port-au-Prince which currently is the hub for the SBC medical work.

The two story building and outbuildings withstood the earthquake except for some minor damage. The cinder-block wall and buildings are across the street from a residence with upper floors collapsed to the ground. Vans, trucks and “tap-taps” (converted trucks with benches for seating) come and go in the yard crowded with boxes, luggage, suitcases, water units and a few local merchants selling souvenirs to professionals and serious volunteers with other things on their minds.

Inside is a cramped dining area where a very gracious house staff serves full meals at 7 a.m. and 5 p.m. They also do some light laundry work, giving personal attention to a needed uniform shirt or a pair of drawers and having it ready the next morning.

Bathroom facilities are satisfactory as long as the tapwater goes somewhere besides the mouth. The toilets flush okay; tissue paper goes in the trash and is not flushed. From the shower head rattles a feeble stream of cold water which can get-‘er-done with some soap and a little imagination.

The meals are Creole style with often recognizable ingredients. They are flavorful and plentiful but perhaps a little heavy in ingredients that can bring on a memorable night in the latrine.

Potable bottled water is plentiful. Sleeping rooms are sometimes crowded with double bunk beds which were fine for the moment. We had an air conditioner which worked periodically in our room sleeping six men. It dripped into a bucket and made a background murmur which blended with the late night rainstorms in a way that was not unpleasant. I was glad I brought a light blanket in the coolness of the early morning.

Team organization

The leader of Team 2 was our representative to the higher level planners and our unit director. He must have done his job well because the only concerns I had in the field were medical decisions.

The nurses seemed to be organized among themselves at triage, physician assistance and floating/trouble-shooting, according to their skill sets. One nurse joined our very effective logistics officer, serving as ersatz pharmacists. Whatever minor outrages they would have brought to the US Joint Commission for Hospital Accreditation in their professional activities were certainly no worse than the surgeries performed by the pediatricians. Team 2 was organized like an infantry squad and responded to its leader accordingly with professional promptness and good humor.

Medical facilities and the patients

I do not know how clinic sites are selected for the various teams. Team 2 went daily to a downtown evangelical church which was across the street from a refugee tent city of thousands. We traveled to the church each day by tap-tap, carrying our loads of medicines, equipment and whatever personal items we thought necessary, including lunch and bottled water.

We never traveled without one or two security guards hanging on somewhere. Most of them were Haitians. One was an independent Baptist cowboy from Florida with his own 501-c (3). The Alabama medical team told us one evening that their clinic was the focus of a near riot in one of the camps and they appreciated the watch-care of their security team as the team was extracted without harm.

Also traveling with us was a set of translators. Two had particular insight into English, including an appreciation of humor through a foreign language (a useful skill!). They served with the physicians.

My translator was a young man whose home had been wrecked. He slept with others in his extended family in a tent in the front yard of his residence, enduring the nightly downpours in silent misery. His sister is currently hospitalized in Miami (Jackson Memorial Hospital). She had sustained important trauma in the earthquake and while we were in service together, he received word that her leg had been amputated. Her children live in the tent with him.

We set up a clinic over the sanctuary in a second story room which was apparently ordinarily used as a classroom. The room was about 30 feet across with a door at either end opening to outside stairs. The only light that entered the room was indirect, through the two doorways and through two louvered windows on the masonry back wall. We divided the room in half with moveable blackboards, using one part for triage, waiting, pharmacy and counseling, the other for medical interviews, examinations and sometimes injections and minor surgery. The patients sat, and we worked, on low benches with a few chairs and tables.

The line of patients at the church was formed along the stairs as we entered each day, unpacked and set up. We were there during a three day period of national fasting and praying. This filled the church to overflowing each day but delayed our work, added to the noise level and filled our clinic with refugees not only from the earthquake but from the church service. The differences in neatness, cleanliness and dress between the camp residents and the backsliders were noticeable, but most had in common a weariness and acceptance of suffering which was moving.

We saw more adults than children. A parent with one or two children would typically also have medical issues so it was truly “family medicine” much of the time. The triage nurse would fill out a small white card of patient information on each person, adults with blood pressures, children with temperatures and weights.

The bench of triaged patients would look on as the two doctors, each with their respective translator, did their work. The adult patient complaints were those of routine medical issues with a recurring theme of cough “since the earthquake,” dizziness, itchy eyes, vaginal itch, headache, stomachache (often described as “heartburn”) and “waist” pain (lower back pain).

The children often were said to have “worms” and most of them had cough and intermittent fever “since the earthquake” three weeks earlier.

We had an approved medical response for most of the cases although our formulary was limited. Analgesics, antibiotics and antacids were the most commonly used drugs. Prayers were common - sometimes prayers were all we had.

We saw a few memorable medical cases. A young lady was carried in from the church service, hyperventilating. She did fine with a bag. An older lady dropped from dehydration in the service and she felt better after some IV fluids.

Several old crush injuries required debridement. One martyr with a peri-anal abscess had to decide whether he would rather suffer from his diagnosis or his treatment. With a penlight illuminating the area and his surgeon moving alongside the bench to keep up with his retreating target, his problems eventually all worked out in the end.

The newborns could break your heart. Two had scabies, one extensively. We treated them with topical permethrin (a topical insecticide dangerous for babies) and kept them under observation for a few house before re-bathing them. They did fine.

One newborn was sweating under a knit wool cap tied tightly at the chin, wool socks, a wool sweater over cotton pajamas and finally a diaper wrapped around her body from the waist up and fastened tightly in the back with three safety pins.

She – the mother – was wearing a sweatshirt with the hood drawn and had cotton stuffed in her ears. My translator told me that she was dressed according to folk custom for post-partum mothers and that it would do no good to tell her she was over-dressing the baby. I showed the mother how damp the baby’s clothing was and told her that the baby would need extra fluid. We gave her 10cc syringes of ORT to administer with feedings.

One mother brought three children, one of whom may have had the only case of asthma that we saw. She went back to her tent with an albuterol puffer duct-taped to the bottom of a plastic cup.

When it was mom’s turn, she said through the translator, “My stomach hurts when I don’t eat.”

I had to pause and think about her complaint. Intuitively I knew not to respond, “So then, just be sure to eat!” but I wasn’t sure how to proceed with the interview. This was a moment when I truly appreciated the skills and insight of “Dasy,” my young translator.

“Don’t ask her ‘Why?’” he said to me.

“Why not?” I asked.

“Because if the answer is that she has no food, then you will be responsible to see that her family is fed. That is the way it is in Haiti.”

I excused myself momentarily and spoke with our team leader. We knew there was mass food distribution occurring – it was where the riots were likely – but we did not know exactly where to refer. Our team clinical counselor accepted the lateral and advised the woman on the next step to take in a long walk to recovery.

Conclusions

The situation in Haiti when we left on 2/17/10 has probably changed, now three days later. My experiences were so limited that I could only speak with any authority of the one week in the little hole in a wall where we lived and worked. Obviously things are far better than they were only a week or two ago.

The members of my team, for the most part, had the very useful qualification of having served under third world conditions before. The effective practice of medicine under primitive conditions relies almost entirely on obtaining a careful history through a translator who is familiar with the culture and a physical examination without the benefit of laboratory, imaging or consultation under conditions of poor lighting and distracting noise.

“Therapeutics” is defined by whatever skills the team brings and whatever medicine and equipment it has on hand. A seat-of-the-pants eyewash solution of normal saline was all that was available for “itchy eyes” and memories of a surgery rotation in medical school years ago served to instruct in debridement procedures.

Given the circumstances, I did not feel in physical danger as long as I regarded the rules and the authority structure. Team unity was a priority and we all felt appreciated for what we had to offer without any sense of competitiveness. Cowboys, especially those with MD degrees, should be received with caution on the medical teams.”

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