“...on my final day, my mind tired and body aching, I find myself wishing for a couple more days.”

By Dr. Solomon Kuah
Wednesday, February 10, 2010, 4:45 PM, Port-au-Prince, Haiti

If only I had a couple more days . . . I have spent every day of the past 26 days working at the Port-au-Prince University Hospital.  I am on the last notch of my belt, sun-burned, dozing off during the rare standstills, and wondering if I should be worried about urinating only once a day.  I have battled sickness, heat exhaustion, dehydration, and near-narcolepsy without faltering a day.  Now on my final day, my mind tired and body aching, I find myself wishing for a couple more days.

You've heard the story: it started 2-3 days after the 7.0 earthquake that found us at the University Hospital with nearly 800 Haitians near-death and wounded.  On the first days we worked with our tools at our side, bobbling around with jump bags full of irrigation, splints, antibiotics, pain medicine, sharpies (triage), etc.  The Haitians were strewn all over, lying on either the bare floor, cardboard boxes, stained blankets, or shattered hospital beds.  Too broken to move, they waited for a shadow to fall over them that could signify a doctor or nurse coming to tend to them.  Their faces were sad and they had no tears to cry, but if they could just reach into the shadow, someone might notice they were alive. Our relief team masked the shock and ignored the quiver in our hearts.  We worked with speed and diligence.  We were committed to these people.

As the days passed, we secured shelter and water for our patients.  Other relief teams poured into the hospital and we evolved from the bumbling individual with 2-to-3 jump bags slung over each shoulder to a clumsy system at a maximum 57 agencies, all setting up shop around the patients.  The system was anywhere from fast and fluid to confusing and redundant with some days a flurry of activity and others a standstill.  We scurried around with faces of many colors while our patients lay still in their cots watching in apprehensive confusion, unable to move.  I visited nearly every one of our original patients, every day for the past 26 days - maybe my unique 'Chinois' face would serve as one thread of consistency. One can only wonder if this reassured them.

Each day we chipped away at these numbers and the patients slowly got their much needed interventions.  Smiles began to surface and family members occasionally danced in the space between tents.  Most smiled back at me every morning, some would even wave, some would not, and others simply could not.  Life was coming back into their bodies and now it was time to start preparing for their life outside the hospital.  Rehabilitation and physical therapy centers having been popping up throughout the city over the past week and a half.  As a center opened, we would offer them a transfer but most would initially refuse to go. They were afraid if they left, they would die.  This is a society and culture bent by a failed state to not trust what they could not see. I would visit each center and 'report' back to the hospital.  'Reporting' used a phenomenon called 'tele diol' or word of mouth.  It found most the centers calm, well staffed, and appropriately equipped.  Upon return I would have one of the local Creole translators tell one family member, ˝the 'Chinois' doctor just came back from the rehabilitation center and he thinks it is very good.˝  By the next morning, nearly all were willing to go. Just remember, 'tele diol', it can be used for good or for bad.

It is my final day and we have approximately 90 of our original patients left.  A third still require a final orthopedic or plastic surgery intervention, with the remaining waiting for the hospital rehabilitation facility to open.  International Medical Corps has been working closely with Handicap International to open a rehabilitation/physical therapy center on campus.  It is nearly complete with the truckload of equipment coming tomorrow.  This means within a week we could potentially see one of our first patients walk out of the hospital by themselves.  I've longed for that day.  I will miss that day. If only I had a couple more days.

Although I am the only person left from the first International Medical Corps team I have had the company of my patients.  I have three names: 1) 'Chinois', 2) 'Jackie Chan', 3) Dr. Sol, and 4)'the humble doctor'.  One mother with an above-the-knee amputation of her left leg requested I support her as she guided me into the hospital courtyard.  She took me to watch the children dancing and singing. We sat for 5 minutes, silent, until she said 'thank you'.

“It has been the longest week in years.”

By Dr. Solomon Kuah
Monday, January 25, 2010 7:55 PM, Port-au-Prince, Haiti

It has been the longest week in years.  As the dust settles we find ourselves in a 'second' disaster - the thousands of NGOs, volunteer group/individuals, journalists, celebrities and political entities in a backdrop of tons of materials and supplies, both useful and useless.  In this,  our team has established itself as the leaders in clinical health care by being the first to deliver and the one to coordinate the only semi-functional hospital.  Well . . . it is a tent hospital.  There are 11 tents/wards, with nearly 500 beds, and 2 more tents coming.  Our International Medical Corps team has grown with fresh faces and clean t-shirts - a contrast to the now rag-tag appearance of our original team.  Most of the new volunteers have enlisted to run mobile clinics and outreach and see mostly primary care.  In the hospital it is a different story.  Imagine Port-au-Prince on a good day, now we are in post-disaster.  We see 300 patients a day and do EM/trauma in 2 tents.  Again, the dust is settling.

We lead and 'coordinate' approximately 50 teams/NGOs working to establish a functional tent hospital.  We receive large amounts of resources from the Clinton foundation, USAID, Sean Penn and Wyclef Jean; I've met them both. We've created standard registries to keep track of our patients and conduct epidemiologic studies in this mess of a response.  We've actually had a few patients disappear, yet the clinicians are very reluctant to adopt the registry, but we'll continue to push the importance.  

Despite trying to coordinate all this I get to see some patients.  I've had multiple GSW's (I haven't seen a gunshot wound since being at CU) and a Typhoid perforation.   I have a skateboard coming in from one of my local translators, this should make me more mobile to accomplish my coordination tasks, then can I get back to patient care.
Tomorrow is another day.

“You need to remind yourself that your skills and equipment are not the solution...”

By Dr. Solomon Kuah
Tuesday, January 19, 2010 10:42 PM, Port-au-Prince, Haiti

I've questioned myself and the skills/sensibilities of an EM physician in extremely chaotic, austere situations like acute phase disasters. Doctors are needy, have very specific windows of comfort, and often are a lot of "baggage". These qualities are counterproductive and frankly dangerous in situations where infrastructure is destroyed, inhibiting, and dangerous.  You need to pack light, get out there and determine what needs to be done.  You need to remind yourself that your skills and equipment are not the solution.  You need to remember when you go home their world and bodies are still destroyed.

Our team is a clinical powerhouse.  Lead by the tremendous father figure and wilderness medicine genius, Paul Auerbach. Our role model and sergeant is Stanford chief of EM, Bob Norris. Stanford wilderness medicine and Columbia international EM fellows march to their guidance and try to work one to two steps ahead.  This could be the dream team of clinical disaster response.

However, this is not enough.  ER intake, three wards, and 2 ORs later we are overwhelmed with thousands of rotting wounds, open fractures, crushed femurs, and maggots.   We ran out of ketamine and narcotics twice already - those days you could hear the screams outside the wards echoing louder through the compound.  Another supply of ketamine and narcotics would arrive - enough for a sigh of relief and then we'd run out again.

We can only prioritize open septic fractures to the OR.  The remaining, who would easily go to the OR in the US, are admitted for their daily morning shot of rocephin.  They wait for their operation, and are still waiting.  We put them in traction and debride their wounds at bedside.  I've only put in 2 styman pins in the past, I've now increased that by 10-fold.

I will never forget one patient’s bruised, swollen smile as maggots crawled out of her gums.   I will never forget the smell of oozing, rotting flesh.   I still hear the screams of pain on the days we were out of narcotics - you don't have time to wait.  I will never forget the young girl who reached to touch my face, only to realize that her arm was gone.  She cried and said thank you, that she loved me.  I will always remember singing to a 2-year-old child to distract her from the compound's tornado of noise, devastation, and tragedy.  I sang the same song a dozen times as my arms trembled in our 1-mile hike to the pediatric ward - she weighed over 50 lbs in her bilateral lower body spica cast.

Tomorrow is a new day.  I will take comfort in a clean set of clothes as I sling over my shoulder 2 jump bags which are spilling over with materials for fractures, wound care, and pain control.  Tomorrow we will work.