HAITI, A CAUTIONARY TALE OF CONSCIENCE
Headlines of human tragedy bring out the refocusing of our priorities.
With the onslaught of media coverage of the earthquake there was little doubt as to where I felt I belonged.
I often hear people speak of giving back and when I do, I feel on some level offended. I have always felt, being a physician was a gift, and being allowed entry into the most intimate parts of others’ lives was a privilege with its own rewards. When a magnitude 7.0 earthquake struck southern Haiti on Tuesday, January 12, serving there was not a matter of giving back for me. In that moment I felt I belonged there.
Still , when medical students at Touro asked me what they could do to help I cautioned them to be prudent and not to get on a plane and go to the center of the storm. I told them perhaps the hardest thing I had to say to any student of the healing arts. I implored them to focus on their skill; to hold onto the emotion, and place it in a cherished savings account. After decades of work in developing countries, I had learned that wanting to do good is just not good enough.
After my lecture I went home and again set to work to find the venue for my skills and needs.
I made numerous calls to a friend in the Clinton foundation and several to a close friend and patient Jeanette Williams, the widow of a former US Senator. Through her introduction I received a call from Mike McCurry, Bill Clinton’s former spokesperson. Both he and our friend at the Clinton Foundation had given me the same name to contact and after a call to President Clinton’s undersecretary for Haiti I received an email from an organization called Association of Haitian Physicians Abroad (AMHE), asking for my “credentials”. I sent them all of my data with little hopes of response. To my surprise, I received a call the next day informing me on a Thursday afternoon that I had been selected to go on standby for a flight Saturday morning. They informed me that I was to bring enough food and water for a week and to be at Kennedy Airport at six am. They said that they would confirm my status at nine pm Friday night before the flight and that there would be a group call at that time. As someone who has planned medical trips to emerging countries before, I was incredulous about the situation and my wife was even less than enthusiastic. Serendipitously, while lecturing to the vascular surgery department at Robert Wood Johnson University Hospital Thursday night I came upon an old friend Paul Hasar M.D. When I told him of my plan, fully expecting him to echo a dubious sentiment, he surprised me. He had made plans for a long awaited vacation to the Bahamas but told me he was more than willing to cancel his plans on the spot to join me in Port-au-Prince. It was in this moment I realized that I was about to embark upon a trip of consequence.
That night ended with a flurry of calls, and ultimately the tenebrous compilation of lists of personal and medical needs for the trip. I called the administrator of the local hospital and was warmed with his immediate and generous promise of supplies for wound care, which is my specialty. I then spoke to all of my five children separately to explain myself, and they were equally enthusiastic. This left my wife, who unlike my children suffered no illusion about my good judgment, having known the gamut of mine over the years. She was reserved, but likewise understood the need to go, and the draw of this moment in time. The nightly news was cased with stories of the horror and rumors of aftershocks in Port-au-Prince which made my reassurance to my parents less convincing. As a consequence what I wanted most was to move on and begin.
Upon awakening the next morning, I brought four giant suitcases to the hospital. My wife went to the store and bought 150 protein bars and four jars of peanut butter. She also went to the sporting goods store and got a mosquito net. My daughter went out and got two palates of water and I felt as if things were falling into place.
It was not until eleven pm the night before our departure that the ledger sealed my name among the chosen. So many metaphors stirred in my thoughts. The notion of being, “the Chosen” having grown up as a child of privilege in a Jewish home in New Jersey made me chuckle. But the recollection which moved me most at that moment was the memory of my physician father accompanying a child with a terminal condition back to Puerto Rico on a small plane to die in his native town. My pride in that deed fueled many sleepless nights in medical school and residency.
The next morning my wife and daughter Emma drove me to the airport. We were told to find the men with the yellow jackets for further instructions. Upon our arrival we were somewhat blindsided by the subscript on those Jackets which read “The Church of Scientology”. Now I know very little about the church of scientology but what I had known was steeped in kookiness. My wife looked at me with a mix of anxiety and disgust, gave me a kiss, made some comments about my judgment and said see you in a week.
The preamble to our flight served to only heighten my anxiety. Our group, it seemed was to be embedded with the Jersey City fire and Rescue Squad; and that of Bedford Stuyvesant. We were wedged between cadaver dogs and traveled along with a mixture of expatriate Haitian nurses, doctors, and other assorted renegades. The person sitting next to me on the flight was a 280 lb young man with BED-STUY carved into his hair cut. Next to him was a dog, which incidentally got a whole row for himself. I felt like I was thrust into a surreal menagerie. I remember once reading somewhere that the more bizarre the experience the better the story. Now this may be true but that presupposes a good outcome, which at that point I was unsure of. Our flight was delayed and our in-flight experience was punctuated by a slew of what I would become accustomed to in the week to come, rumors! Once in the air, the pilot informed us there was a chance we would lose our, “three minute window for landing” We were told we had been granted a special landing slot as civilian flights were not going in. Ultimately we did make our slot. As we were preparing to land, the pilot came on the loud speaker and preempted a very rough landing. Paul my new 19-year-old search and rescue buddy offered me a swab of Vicks Vapor rub for my nose. I looked at him perplexed, “to hide the smell of the bodies,” he answered. At that moment the seemingly histrionic tough guy, bravado pierced what had heretofore seemed inconceivable. The feel of the ground gave me again a mixture of relief and disquiet.
Our exit of the plane was the beginning of a fantastic experience. There were military planes and helicopters everywhere.
Military troops of every possible country abounded. I had never seen anything like it outside a scene from Apocalypse Now. We unloaded our supplies and kept them close to our person. It was clear from the sounds in the night that this was a war zone of epic proportions.
We loaded our supplies into a large Garbage Truck and jumped in. The walls of the truck were high enough as to block any vision, which was by design. The people of Haiti had been the poorest in the hemisphere before the nightmare .Now we were in the latter part of the first week. Food and water were scarce and the streets were dark and void of police. Our organizers again had on their yellow shirts with The Church of Scientology on them. They were young but clearly dedicated and seemed to understand the problems on the ground. I was reminded of a stanza from Henry V the St Crispin’s speech,
“We few, we happy few, we band of brothers;
For he to-day that sheds his blood with me
Shall be my brother; be he ne’er so vile,
This day shall gentle his condition;
And gentlemen in England now-a-bed
Shall think themselves accurs’d they were not here,
And hold their manhood’s cheap whiles any speaks
That fought with us upon Saint Crispin’s day.”,
I felt a sense of relief, one more prejudice unmasked. I looked at these young people with a new respect. They had skin in the game and they showed up!
Our ride to our compound was one void of sights. Only smells would interpose our sensory deprivation. The sounds were muffled by a loud engine sans muffler, but the smells were pungent. It was hard to know what they were but it was not hard to imagine. The Vicks, the smoke, and the smells within the garbage truck were disorienting.
We got to the compound, which was only three to five miles from the Airport. It had been the home of a Scientologist; who had agreed to allow us to use the grounds during the mission. Upon our arrival, I was profoundly relieved to find our group would be surrounded by a tall secure wall and barbed wire. There was a place to shower and a bathroom, which made our accommodations the Ritz from my standpoint.
No buildings were suitable for shelter but as luck would have it the weather was lovely. I called my wife to tell her how beautiful the night was and her response gave me pause. She said it was just like 9/11, where the beauty of the day was such a sharp contrast to the horror of the event. We settled in and put our sleeping bags on the ground. We slept on concrete in a mosaic of bodies as no building was safe. My mosquito net had gotten lost with one of my bags and my water never made it to the compound.
Still, I could not express my relief knowing we had acquired some safe high ground to retreat to at day’s end.
Though we were all quite tired, there was no rest for the weary. No sooner did our heads hit the ground than a symphonic cacophony of sounds stabbed the air. The sounds from my colleagues of the search and rescue were some that to this day I cannot believe are found in nature. They seemed to intercourse with each other reminiscent of a light motif. When the snoring found its silence in moments of apnea, the ground began to tremble and the sky was filled with the roar of huge cargo planes. As if that wasn’t enough the dogs sang the chorus, barking to one another like a telegraph. Of course by now there was no surprise when the neighborhood’s mentally challenged roosters, who clearly did not get the memo about beginning their antics at dawn, began to crow.
Morning came and our rumbling stirred the grounds. We all began to organize our things and found some industrious locals selling Haitian Coffee. It was like rocket fuel and I felt ready to move. A large bus pulled up next to the compound and we sandwiched our supplies and personal items in between our bodies.
The bus began rolling down the winding roads and for the fist time daylight bore witness to the devastation. It was almost impossible to believe but no building was left unaffected. The streets were filled with the displaced and the rubble was everywhere. Live electrical wires were ubiquitous and sporadic temper flares were commonplace.
Even from the bus, the eyes of those on the outside were bemused.
Our access to the General Hospital had us pass by the Presidential Palace. The Palace previously had embodied the most regal, even opulent, of this otherwise depleted island. Now looking at the debris of this great building epitomized the quintessence of the earthquake’s destruction. .
Though I have always respected their sacrifices, I have never had a high regard for the military. I have always found it hard in real time to identify with their assignments, and have seen their mission
statement as the conflicting with my own. The mission of United
States Military, in Haiti under Presidential dominion astounded me from start to finish. They combined an extraordinary assemblage of discipline and talent segued with youth and desire for good. No request was too much for them and the security they provided was the underpinning for all the work, which was to follow. Here again, I found my personal prejudices a source of embarrassment in a time of clear and present need and peril.
We entered the gates of the hospital and unloaded our equipment.
Within minutes, we were at our new posts. Because of my specialty in Vascular Medicine, I was assigned to a postoperative tent. Our first morning was filled with a combination of getting to know the environment and attempting to impose a structure upon a somewhat chaotic situation. Locating medications and analgesia for the never ending wounds seemed an overwhelming task, but it wasn’t long before I began to realize that though the magnitude and extent of peoples injuries were of unprecedented proportions, so was the human response to it. As each hour passed, I engaged more and more colleagues. I was overwhelmed with not only the quantity but quality of the volunteers.
Many faces serendipitously were friends and others familiar from national meetings. There was a steady influx of teams from United States and all over the world. The work was constant and we congregated as a team to develop strategies of care. There were so many injuries and they were sustained by such a wide cross section of patients. It became clear early on that the imposition of process was the key to “Best Care”. I could not help but notice that from the moment of our arrival we worked as many arms of one-body. The needs seemed endless and everyone worked tirelessly.
I was initially put in charge of a postoperative tent of fifty patients, which grew from one tent to two by the end of the first day.
There was so much which was absent from other experiences in my professional life. There was none of the usual jockeying for position.
Everyone seemed completely comfortable with our situation. One person was the director of our group, Bob Norris MD. Bob was both engaging and humane and was the chief of the Emergency Department at Stanford .The rest of us were worker bees. Regardless of our standing back at home, regardless of our academic post, we were there to work and there in the service of our patients. As crazy as the need seemed, our response seemed appropriate.
We instituted a practice of SOAP notes (Subjective, Objective, Assessment, and Plan) on all of our patients with each service putting their label on the chart. We spoke with the nurses and began a rigid process of assessment and documentation on each patient. The times and dates of each debridement were placed on each dressing and physician rounding mimicked the rounds of the nurse assessors. Every patient received subcutaneous heparin for Deep Vein Thrombosis (blood clots) prophylaxis, a practice we rarely accomplish so effectively at home. After our initial rounding we would do dressing rounds. A nurse would precede our arrival and analgesia would be infused intravenously. I was amused by this altered reality. I initially petitioned for narcotics to the tent. I went to the Director, and he gave me a big box for my backpack. When I looked inside there were two hundred syringes with 20mg in each of morphine sulfate. At home asking for three mgs of morphine to inject into a patient with acute heart failure would invariable spark two to three nurses to follow me to the patients bedside until the last drop was infused at which point the remaining evacuated vessel would be summarily confiscated. Here I could barely carry the volume I was given and no signs of a nursing trail was apparent Our routine began to make sense, and our relationship with the other services gelled in a way that seemed dream like. When a patient needed surgical intervention, we could call teams from the Mt Sinai ; Dartmouth; Médecins du Monde (Doctors of the World), a group from France; as well as the hosts of others from around the United States and around the world. The response from each team was as rapid as we could ask for and the quality of their intervention rivaled care anywhere. As the days progressed the problems changed. As anticipated, we marshaled the transformation from acute trauma, to Guillotine amputations, and to more definitive levels of amputation.
We began to develop an understanding of who among us had what equipment and what skills the different teams had. As the Finnish Red Cross had a skin Dermatome, we found a fertile stream of solutions to degloving wounds, but with it, new problems. By the fourth day, we began to see more flies and the color of some of the wounds began to take on a green hue with a sweet smell. This was followed by other infections and maggots feeding upon dead tissue.
Though there was no paucity of tension, the wit of our team seemed undaunted. The gallows humor so commonly apparent in other situations was absent in our unit. Still, there are times, which even now, three months later, when the seasons have conferred a multitude of color upon the gray of New Jersey winter, I laugh to myself. Though our time there had clear purpose, I will not soon forget the time when my close friend Paul Hasar needed a room for an emergency amputation. All of the operating rooms were full and he heard that the French team had an open slot. He went to the Anesthesiologist Jacque Bruna MD to plead his case for time in their operating room. He presented his credentials to the Dr Bruna. He told him he was a professor of Surgery at Robert Wood Johnson and that he was boarded in Trauma, as well as Vascular and General surgery. He further reported the urgent need for operation. The French anesthesiologist stared at him stoically. In fact, it was unclear if he had understood what my friend had said.
Therefore, Paul did what any good American would do, he repeated himself, this time more loudly punctuating his request with sluggish deliberate and measured pronunciation of each syllable. Dr. Bruna allowed him his second humiliating attempt at communication when he responded. “American?” Paul began his third attempt at this impromptu credentialing committee of one. Jacque then said “not British?” Paul perplexed said “no!” To this Jacque said in perfect English “Sure come on in, as long as you are not British”.
A steady stream of the media continued to meander into our tents.
Their presence was a constant source of cognitive dissidence. Though they on so many levels seemed to be ghoulishly voyeuristic, we were under no illusion as to the power they wielded in bringing the message of this suffering to the worlds attention. At one point, I saw a colleague from home Jean Paul Bonnet, a D.O Family Practitioner from New Jersey walking through the courtyard with a stretcher. Even more surprisingly a young Military physician walked into our tent to assess our progress. The usual inquiries ensued of “Where are you from and where did you train?’ He laughed and said he was from Missouri and the place he had gone to school would, in his words, be unfamiliar to me. I told him that just from his description I could be sure we shared the same name on our diplomas. He could have been knocked over with a feather clearly corroborating my wife’s’ dictum that you are always one Osteopath away from any other Osteopath in the world.
These peculiar occurrences seemed to have no end. As the week progressed the wounds continued to be a problem; I came to the conclusion that in order to stave off a wildfire of infection we would have to segregate our “clean” and “dirty” wounds. I proposed to Dr Norris that we needed another tent to this end. Though he agreed, there were no additional tents to be found. I again called a friend in N.J who put me in touch with a New Jersey Congressman’s office. I received a call from one of his aides that was of no help, and was seemingly more interested in appeasing a constituent than actually getting us a tent. After five calls back and forth I gave up on this congressman. It was clear that his office had no skin in this game.
The next day as the patient’s wounds became increasingly purulent; a man with a southern accent came up behind me. He said he was an Orthopedist working at another hospital. He offered to take forty patients from us either clean or infected. He told me they had fully functioning O.R s and would be happy to help. I was so happy I could have kissed this guy. We talked about the patients and of course I asked the perfunctory “where are you from and where did you train?”
He told me he was from Kentucky and that he had trained at the Cleveland Clinic. I was dumbfounded. I said you’re kidding so did
I. I asked when? He responded he said he had finished his training
in 1989. My mouth dropped and I asked if he knew a guy who I had worked with very closely, Phil Hurley. With this, he looked at my tag and said “Bruce?” I said yes, but do you know this guy because we fell off each others globe when we left The Clinic. He again said “Bruce?” At this point, I was beginning to think he was a bit slow, but he post scripted with “I am Phil Hurley!” I told him he could not be Phil Hurly because his hair was all grey and he looked like an old senior staff attending. His response was equal to my quip.
“Listen the Bruce Mintz I knew was skinny, and had brown hair and this one is fat, and old with a scruffy white beard”. We embraced, but in a moment he was off and we were back to work.
When the trip began, I sequestered my old hand held Doppler, which I have not used for years. I was quite proud that not only did have it, I remembered how to use it. When word got around the camp that I was a vascular specialist, the requests were repetitive for requirements to rule out Deep Vein Thrombosis (Blood clots). I pulled out my Doppler with great pride showing it to the Stanford guys. As if pulling out cannon from their bag they answered my war torn 30 year old handheld Doppler with a Brand New high tech Duplex ultrasound. He said, “Would this be a bit better?” I am sure they thought my life was lacking in substance when they saw my grin from ear to ear. They had a brand new Doppler, which I had just evaluated, at our hospital for portable use. In between my care of patients on the ward, I would be called for emergency venous ultrasounds and could not believe the care we were privileged to offer.
The unit seemed to be functioning well. Fate had afforded so many good turns. At the end of the first day, an angel came to our tent He was a sixty year old seasoned towering black no nonsense internist from northern California. Harold Orr MD. He offered to take the whole week’s night call. The night promised nothing good, but his skills drew my awe. He reinforced my optimism; we could indeed live in the days of the giants.
As the end of our trip began to approach, a new sense of anxiety cloaked my senses .There was no clear recipient of the baton. When we began to ask about our transition we were told that the Embassy dictated we could only depart when we were relieved. The ethics of the dilemma was clear to all of us, but our personal situation was still tenuous. We knew we could not leave until appropriate surrogates could take our place but we had already strained the charity of our coverage back home. My wife was likely interviewing my replacement, in fact she was once asked if she would ever marry if something were to happen to me, she responded.” to another man, heavens no “. Again, in the darkest moment of this anxiety, a group Twenty seven Physicians from Rush Presbyterian in Chicago came upon the scene fresh and sleep revived. They were headed up by David Ansel MD, their Chief Medical Officer and Walter McCarthy MD their chief of Vascular Surgery There was a sense of respite which was palpable. Confident that our patients were secure in the arms of both compassionate and competent academics from Rush, we were gone.
As unceremoniously we had arrived, we were grabbed to the airport. We had had no documentation of our visit. To the world, we had not been there. I had no stamp on my passport to mark those days in Port Au Prince. When I thought of it, I had not seen any of the countryside. The breadth of our experience would be limited to an airport, a concrete slab and a tent city Hospital. The stamp was in the tattoo of our time and in the faces of those who had permitted us into their lives to share in their tragedy.
Since childhood, I always recall my mother prevailing upon me to ask the hard question upon leaving a place. What was learned? There was no moral in Haiti. The tragedy was, though massive, of no one’s doing. I could not point a finger at a culprit. Now I found myself in uncharted waters. What do we take away from experience that is unfathomable? I could come up with precious little to account for my time on this brown Island. What was unambiguous to me was that nightmares are sometimes the price of conscience. There was no surrogate for skills, and there could be no substitute for action.
Ultimately there is no hiding. To be a citizen of this world we all must come to grips with the reality that there can be no spectators, and we all have skin in the game.