Work in Haiti

Firstly and with hoards of gratitude, to say THANK YOU to all who spurred me on to go to Haiti and especially to those who gave me financial assistance whether directly or through the website. I could not have gone without your help. To those of you who missed my Christmas card (as I sent none) this overview is by way of an excuse and general update. Honest, I was too busy!!

I have always believed that there is sufficient charity to be done on our own doorstep so when I was first asked if I would like to go teach Wound, Ostomy and Continence Nursing in Haiti I was inclined not to. Then I thought, hang on, I will be unemployed by the end of the year and no one is interested in  what I do so why not go somewhere I am needed and appreciated (obviously motivated quite selflessly). I melt in too much heat so I planned a Dec trip.

I set off from Hartford to North Lauderdale in order to see my brother Robert before heading out. I stayed a couple of days and acclimatized myself to a warmer temperature. After an evening gig Rob dropped me at Miami at 3am Saturday the 5th Dec: not many souls about but by 4 I had merged with a small group of nurses and docs. Some had been over to Haiti before and all were from North Carolina or Minnesota (the trip being organized by someone from their facility). Me and Nick, an ER doc from Canada, were the only loners. Once there a couple of pediatricians from New York joined us. Most of the nurses were from the ER or ICU and nearly all were much younger than me.

Things got off to an interesting start when it was apparent that some bags with donated supplies could not come with us (very strict about luggage allowances), so a few of us had to pay the excess bag charge (and state we had packed the bags ourselves, oooooh!). I have no idea what was in the bag I said was mine but it was also too heavy so I had to extract an ambubag and some other device and put them in some else's hand luggage. Some luggage of course, never arrived anyway, though it did wind its way over later in the week.

It was hot when we arrived in Port au Prince at a newly opened airport very different from the one others had seen previously. After the earthquake in 2010 the airport was badly damaged. Of course, fixing the runway was a priority but now the airport complex was nearly finished and impressed those who were return visitors. There were plenty of red-coated porters waiting to take our bags but we had been warned to avoid them. Our taxi was a TARDIS in which, we learned later, could be squeezed many,many people plus one, if someone lay down the middle on top of all the knees. The Bernard Mevs Centre was not too far from the airport but the drive was almost as interesting as Istanbul in rush hour (quite an appropriate term for both venues, congested but not at all slow). Fear is of course easily overcome by closing ones eyes. Many of the streets are narrow with vendors on both side, children and dogs tempting the traffic while taxis and ptap ptaps jammed full, expertly navigate the road, .... pavement and sidewalk.

What is a ptap ptap you ask (I may have spelled it wrong but it does have a p somewhere). It is a type of fairly open minivan-come micro-bus with a touch of sixties, hippy psychedelic paint job and often a charismatic Christian quote splashed across the front or sides. To board it you gesticulate and yell, it will then cut across streams of moving traffic and slow to allow boarding. To jump off you tap a couple of times (by sticking your arm over the side and slamming it against the side of the bus). Everybody uses them including school kids (no mamby pamby yellow busses holding up your commute here). So our much more sedate transport ferried us in the midday heat towards our compound. We squeezed down the side street in one of the shady parts of the city.

Bernard Mevs is on the edge of one of the less salubrious parts of Port au Prince. It was built as a healthcare-clinic-come-rehab and was abandoned but mostly left standing after the earthquake. It has large double security gates and a central area where, as you gaze skyward, you see a double arch, untouched by earth's groaning. After the quake healthcare was delivered from the airport area where a tent hospital was erected. It served the purpose well but as things started to normalize it was clear that other facilities in the city would not be able to provide some of what was now available. In particular the emergency care of head trauma, spinal injuries and amputees had become somewhat of a specialty in tent city. There were 200 patients to discharge and relocate and the chosen site would house less than a 1/4 of them.

As we entered the compound Triage was on the left, up several steps, under a screened-off lean-to. Patients sit and wait across the driveway on a bench and are seen and treated according to need. Those requiring closer, personal exams take up the two chairs or stretcher in the lean-to. After triage on the left are the 2 main ward areas, med surg and ICU, and the OR is behind triage. Pediatrics is off to the right after triage, across from the orthopedic and wound care clinic. The spinal injuries unit is further in on the left opposite the lab, both of which I noticed were opposite a portable CT scanner. There also were several infectious disease beds, where occasionally the agonizing sound of labor and first breaths of a delivery could be heard.

Out we jumped and off to orientation after which I decided I would have a general nosey around and settle for a while on the spinal injuries ward (run fully now by Haitian staff). It had been made clear in orientation that the hospital was in transition due to the government insisting it start to charge for services and become self sustaining. This had meant a massive reduction in staff, including translators. I had been told not to worry about my French being poor... I really wish I had ignored this advice and more than brushed up. I sat in the unit reading charts in French piecing together what had happened to the 7 men there. I offered help with some re-positioning but found it difficult to communicate. Translators were available but not where I was so I managed with my French and laughed with the relatives and patients as the nurse busied herself with drugs. While I was reading the charts, I realised the relative of one patient was doing basic care for all the others. The woman helping the patients to reposition, wash and eat today was prompted by the nurse at times but mostly carried out her duties quietly alone.

The spinal injuries unit has become a big family and those that have been discharged remain members, coming back to a project planned to change a cultural paradigm: Project Stitch has been developed to help provide meaningful productive work for wheelchair-bound people. Disability and deformity stigmatize people in many cultures and finding work is difficult. Being valued and productive is an important part of our humanity and Project Stitch is attempting to shift cultural norms and it is succeeding. The variety of products being made are numerous, of excellent quality and can be customized. The men are once again providing for their families as they recover and take prominent roles in the community.

I found lunch and was pleasantly surprised as there was a veggie option. Later in the week one of the veggie meals was French fries, potatoes and rice. Interestingly diabetes is a big problem in Haiti. On Sunday I did a twelve hour shift in triage with a Haitian EMT and had a variety of fairly straightforward patients. Only one minor gunshot wound, 2 stabbings and a couple of lacerations that weren't too bad (though one may have been domestic violence). We managed our lack of communication with some difficulty and reverted to a translator a few times. Something rather funny happened too. We were not too busy for a while and the EMT started to sing, I recognized the tune, a Scottish love song (Drink to me only with mine eyes) so I joined in with her, she was soooo surprised but continued. We sang it through a several times with me eventually trying a harmony, not sure I quite made it so we laughed.... a lot.

I was asked to see a patient with abdominal fistula and was pleased I took over my ostomy kit with me. While cleaning the skin around the wound I asked the nurse for a washcloth and water, she gave me gauze and saline. Interestingly when I did his dressing the next day a relative of another patient was intrigued enough to come over and intensely observe what I was up to. I was rather engrossed and knew I would not be able to make myself understood, the patient didn't seem to mind so I demonstrated my skills and said nothing!! The lack of water for washing people was just crazy. Two taps: one outside the children's ward and one near med/surg. I used gauze / tissues and saline much more than I needed to. The water is there, it just needs a small amount of plumbing and why this has not happened is not clear. As for the  lack of laundry (washcloths, towels and sheets) I appreciate this is problematic and a less easily solved issue. 

Monday and the wound clinic was open. I arrived at 8:30 to find everyone busy getting the rooms ready for the day. They were also folding gauze so I joined in. The RN who runs the clinic acquired his position after the quake and now works with Dr Francis who is the director of wound care. When the RN arrived he explained I would see patients with him for a while and I got stuck in. We saw some new people referred from triage and med/surg but mostly they were follow ups. I will not give any gory details but I will tell you that by the end of the 1st day I had started to clean everything and had noticed something that really surprised me.

Privacy for me means many things but as a healthcare professional the most important is government legislation (HIPAA). The other biggy is the basic right to be alone with, and have the full attention of, the professional working with you, and knowing others can not see what is private and personal. The clinic had screens and I would be careful to keep them closed and cover patients appropriately. I was thanked every time and soon became more and more conscious of this gratitude. I would be starkly reminded of the lack of privacy available elsewhere in the hospital when I finished at the clinic and saw a couple of patients each eve. No curtains or screens available anywhere, not even on the mixed med/surg floor.

On Wednesday we had an excursion to a local orphanage. The docs did a basic exam and we weighed, measured and recorded the name and DOB of each child. They were a happy, mostly healthy bunch of kids from 2-18 years, they look after each other. The head of the home is a middle-aged woman who had started the orphanage in her 20's. Her home is on the same site and it is modern, arty, open and airy. The secondary schools have a school uniform and, impressively, somehow the white shirts stay fresh and white looking. It was great to visit these kids (getting outside the "compound" was a definite bonus), they sang for us and were playful and happy. The journey there and back was of course fairly tense but seeing the city unfold was very interesting. A dusty, dry place, vibrant with colour and the bustle of people at work and play. There are large roomy palacial new buildings but they can only exist behind large gates with guards (they looked empty). We saw evidence of amazing hotels and Malls but evidently many slums with contaminated water still linger on with residents waiting hopefully for re-housing handouts that were used at one point to re-locate people. Shops are open, airy and must be manned 24/7. Buildings are made from concrete blocks and many structures use rubble for the building material... and no mortar. The next earthquake is likely to be as devastating as the last though I am told the water and sewage infrastructure is now becoming sound and sustainable. To the North recovery is more complete and in the hills any hardship was shortlived. The rich are richer and the poor remain in their daily struggle.

Sleeping was not a problem for me as I found the bunk-bed comfortable and my mosquito net behaved well (staying in place). I woke up early and enjoyed the singing from a church over the road. I tried recording it but just got a lot of traffic noise instead. One of the nurses got more than a little distressed at the sight of an exceptionally large cockroach in our dorm, next to her bed. I watched as the offending insect was expertly dispatched. As I turned I noticed a mouse on the top of the same nurse's suitcase and thought it better not to draw it to the poor woman's attention (her throat was already sore, me thinks). We had a shower, toilet, sink and cooled filtered water bottle between each group of 6. I ate what I was told was ok (I was dissapointed there was little fruit though), drank lots of water and managed to stay well.

The clinic was busy with many things I would normally see every day (if I had a proper job): plenty of venous and arterial disease wounds on the legs, more diabetics than I expected. Scalds, burns, abscesses and sores. Some of the worst wounds I saw were bad because people sought treatment too late. I had students with me in the mornings; a few tried out their English but mostly I stumbled with my French: such a shame!

I spent Saturday morning in clinic while the next week's US volunteer nurses eagerly awaited orientation: no wound/ostomy nurses in this group. We packed up and left few reminders of who we were. The airport was almost like any other and we returned to a different life.

So, a few final reflections. Having a CT scanner and top radiologists seems somehow to skew priorities: a little pressure to increase water taps and linen availability seems overdue to me (what would Florence think!!). Nurses should make their voices heard on this but I could not hear anything but my whisper. I wondered if it is because we are busy with our role as medical technicians and have let go of what it is that is nursing. To assist people with reaching their goals for health is such a basic function. To help a person maintain dignity while carrying out the activities of daily living means providing privacy in addition to ensuring water and clean linen is available. The most effective nursing is done by peoples loved ones so the professional nursing role becomes one of an advocate and educator. As a US volunteer I had the honour to work with and help a country nudging back from the precipice it was a wonderful opportunity, I learned a lot. If my French can improve I will return.