Haiti medical relief

Medication Donations

2011-11-26T19:49:00.000-06:00

I'm going to be purchasing medications for Haiti soon. As you probably know, this is something I have been doing since late 2010 when the cholera outbreak started in Haiti. With the help of a wonderful pharmacy team at my home hospital in the U.S. (including pharmacists Emily and Heidi), and with the help of generous donations from dozens of people, I've been able to purchase thousands of dollars worth of medications over the past 12+ months. I also continue to travel to Haiti frequently (I spent over 4 months in Haiti in 2011) to distribute the medications and to work with various organizations providing medical care.

Please see these past posts here and here and here for details about which medications I purchase, which organizations they are given to, and which illnesses we're able to treat with these medications,

When possible, we purchase medications in Haiti. Many medications are available in sufficient quantities in Haiti, and it is preferable to purchase medications in Haiti if we can, for two main reasons. First, from a logistical standpoint, it's much easier. And second, it supports the local economy.

However, in many cases, it makes more sense to purchase medications in the U.S. and then bring them to Haiti. I currently have lists of needed medications from Real Hope for Haiti, Heartline, and Dr. Megan Coffee. I would like to be able to purchase as many of these medications as possible. I will again be collecting donations through Haiti Mission Project, a 501(c)(3) based out of Minneapolis, Minnesota. All donations are tax deductible and tax receipts are sent out at the end of the year. To donate by Paypal, go HERE and click on the 2nd yellow donate button (this will specify your donations to be used for medications). You may also donate by check (information and address is on this page). If you donate by check, please write "medications for Haiti" in the memo section.

Thank you in advance! If you have any questions, please e-mail me at jenniferhalverson09 AT gmail DOT com.

Cholera update from Real Hope for Haiti

2011-11-17T18:03:00.003-06:00

Please take a few minutes and read Real Hope for Haiti's post about cholera from today. Real Hope for Haiti's staff has kept impeccable records over the past 12+ months. This post contains a lot of really interesting information about cholera case numbers and trends over the past year.

Please also check out this post which details the incredible efforts of Real Hope for Haiti's staff as they reach out to remote communities, working to educate and prevent cholera, and when necessary, helping transport cholera victims to the treatment center as quickly as possible.

Thank you to everyone who has contributed money to Haiti Mission Project over the past year. Donated money was used to purchase medications and supplies for Real Hope for Haiti's (RHFH's) Cholera Treatment Center. We will continue to purchase medications and supplies for RHFH as they are needed. I hope you can see from the post above that your donations have made a huge difference! Mesi anpil ~ thanks so much!

Cholera: One Year Later

2011-11-01T21:40:00.002-05:00

Cholera has now "officially" been in Haiti for a little over one year. Prior to mid-October, 2010, cholera did not exist in Haiti. I remember when the first Tweets came through, hinting at the possibility of cholera in Haiti. I remember thinking (along with everyone else), "This is the last thing Haiti needs." I first blogged about it on 10/21/10. I remember when the confirmation came a few days later that this was indeed cholera and I remember contemplating the reality of what a cholera outbreak in Haiti could look like--and then watching as that reality played out in real time. I felt very helpless being stuck in Minnesota. Because I was busy with work and couldn't travel, I poured my energy into blogging about cholera diagnosis and treatment, helping people develop cholera treatment protocols, and arranging the purchase and transport of cholera medications to Haiti.

It has been well-documented through extensive research that cholera was brought into Haiti by foreigners who carelessly disposed of raw sewage that contaminated a major river in central Haiti. I certainly don't think that any one individual purposefully introduced cholera to Haiti, but that doesn't really matter--the reality is that choices have consequences, and the carelessness of a small group of individuals has led to an incredible amount of suffering. Over half a million "official" cases (and probably as least that many "uncounted" cases). Over 6000 "official" deaths (and probably at least as many "uncounted" deaths). Untold sadness and grief over the loss of parents, children, siblings, aunts, uncles, and grandparents.

There are now more cases of cholera in the tiny country of Haiti than anywhere else in the world. Think about that.

Cholera will not be eradicated from Haiti--it is here to stay. A new water-borne illness in a place where the majority of the population doesn't have access to clean water. The perfect storm, really.

Cholera is unlike any other illness I have ever seen, in one important way: the speed at which it can kill people. I am not exaggerating when I say that cholera can kill someone in hours. Literally--a farmer can be working his field at 5 AM, start having vomiting and diarrhea at 6 AM, start walking down the road at to try to find medical care, collapse due to dehydration a few hours later, and be dead by noon. I have never seen anything like it. I know the pathophysiology behind cholera infection; I understand why it can kill so quickly--but it is still unbelievable to see it happen. People I know have taken care of patients who have required 60+ liters of IV fluids during the course of their treatment.

Along with incredible suffering, I have seen an outpouring of generosity from both foreigners and Haitians. Many of you who read this blog donated money that was used to purchase medications and medical supplies to treat cholera patients. Thank you so much for caring and for giving. I've spent over 4 months in Haiti since the cholera outbreak started. I've seen these medications and supplies being used to save lives. There are still thousands of people, mostly Haitians at this point, and some foreigners as well, who show up to work in cholera treatment centers day after day, and night after night, providing life-saving care and critical education to thousands of patients and their families every day.

There is hope for the future--Partners in Health has been advocating for a large-scale vaccination campaign against cholera. You can read more about it here. Cholera will be in Haiti for a long time. Thank you for taking the time to learn about cholera, for caring about the Haitian people and for giving of your resources to help those who are on the ground in Haiti continue to save lives.

Update on medication donations

2011-08-07T01:25:00.000-05:00

Hi all,
So far in 2011, Haiti Mission Project has received $10,516.49 in donations designated for the purchase of medications for several organizations in Haiti! Of that amount, $5121.18 was designated to be used to purchase cholera medications and supplies only.

I have purchased medications on 4 separate occasions (5/3, 6/7, 7/7, and 7/28). All of the purchased medications are now in Haiti, with the exception of the medications purchased on 7/28--those medications will arrive in Haiti in mid-August.

$5274.06 has been used to purchase cholera medications for Real Hope for Haiti's cholera treatment center.
$4478.92 has been used to purchase additional (non-cholera) medications for Real Hope for Haiti, as well as medications for Heartline and for Dr. Megan Coffee.

There is currently $688.11 remaining in the medication account. Real Hope for Haiti has been able to obtain (via donations) most of their needed supplies in Haiti. As a result, I haven't needed to purchase any cholera supplies yet. They do currently have one need, and I will be spending a small amount of the remaining money on pediatric IV tubing to be used for children with cholera. I was able to find a great deal online (via Amazon.com, of all places).

The remainder of the donated funds will be spent within the next couple months to continue purchasing medications for Haiti, and specifically for cholera in Haiti. Donations are generally spent within a couple months of being received, if not much sooner. The need for funds to purchase medications is certainly ongoing, so please continue to donate as you are able. Please visit Haiti Mission Project's support page to donate (click on the 2nd yellow "Donate" button).

Thanks so much for your ongoing support!

U2 Twin Cities 7-23-11

2011-07-25T00:30:00.006-05:00

I had the privilege of seeing U2 live in concert (for the first time in my life) on Saturday. I have huge respect for U2 and Bono and the whole band. They combine amazing music with a strong commitment to social justice. These guys have been performing for over 30 years. They continue to draw huge crowds. I'm sure the touring schedule gets tiring. But they keep doing it. I really admire people who use their celebrity to responsibly bring attention to issues that affect people who otherwise wouldn't have much of a voice. At the concert last night, Bono highlighted the famine in the horn of Africa, the recent release of Aung San Suu Kyi, a political prisoner in Burma (and the huge number of other political prisoners who have yet to be released), the shooting of Gaby Giffords, the HIV/AIDS epidemic, and a number of other issues.

The rain poured down for much of the concert (it was at the University of Minnesota's TCF stadium--no roof) but no one really cared. Very few people left despite the thunderstorms and soaking rain. By the end, I was freezing cold and couldn't really feel my fingers and toes but I didn't really care. The night was absolutely amazing...magical...unforgettable.

Here are a couple videos I took. I'll try to post a few more later.

Intro...band entering the arena

Still Haven't Found What I'm Looking For

Cholera is not going away

2011-07-18T23:03:00.002-05:00

Real Hope for Haiti saw a small decrease in their cholera numbers about a week ago, but since then has had a sharp increase again. At 6 PM tonight they had 101 patients. Several more patients have been admitted since 6 PM. This is the highest number they've ever had. Remember that their cholera house is officially supposed to hold 25 people. Please read Licia's most recent post (Monday Update) for more details about the really difficult situations and decisions they're facing right now.

Real Hope for Haiti needs monetary donations. They need money so they can pay salaries for the dozens of workers at the cholera house, buy supplies (such as bleach, garbage bags, toilet paper, soap, batteries, etc), buy diesel so their vehicles can travel into Port au Prince to buy supplies and to pick up donated medications and supplies (sometimes every day), and pay for all of the expected and unexpected expenses that come up when you're running a cholera treatment center 24/7 that is providing care free of charge. Please consider donating to Real Hope for Haiti--go here and click on the "donate/paypal" button on the right upper side.

I just sent a lot of cholera medications to Real Hope for Haiti. You can read about the medications and see pictures here. Medications are just a small piece of running a cholera treatment center, but they are an important piece. I/we need to send more. I know that I've been asking for a lot of donations over the past 9 months (since the cholera outbreak started). I'm asking again because this need is not going away. This is a tangible way to directly impact the lives of people--mothers, fathers, sisters, brothers, sons, daughters--who are suffering from a disease that tends to afflict people who have already suffered much in their lives.

Please consider donating for medications. The way to donate hasn't changed. I'm still collecting donations through Haiti Mission Project, a 501(c)(3) based in Minneapolis, Minnesota. All donations are tax deductible and donations receipts are provided at the end of the year. Go here and click on the 2nd yellow "Donate" button to donate funds by Paypal. If you donate by check, please specify that your donation is for cholera medications.

Thank you in advance.
Please e-mail me with any questions: jenniferhalverson09 AT gmail DOT com.

Donations for Dr. Megan Coffee

2011-07-17T03:16:00.003-05:00

If you would like to donate money towards the purchase of medications for Dr. Megan Coffee, you may do so through Haiti Mission Project. All donated funds will be used to purchase medications for Dr. Coffee's work at HUEH in Port au Prince.

If you contribute by Paypal, please send me an e-mail (jenniferhalverson09 AT gmail DOT com) to let me know that your donation is specifically for Dr. Coffee. If you donate by check (address/donation information available here), please specify that your donation is for "medications for HUEH" in the memo section of the check.

Haiti Mission Project is a 501(c)(3) non-profit organization based out of Minneapolis, Minnesota. All donations are tax-deductible. For tax purposes, donation receipts are sent out at the end of the calendar year.

Thanks!

Mesi~thanks!

2011-07-15T15:08:00.002-05:00

We raised $3445 to purchase cholera medications for Real Hope for Haiti! I purchased a large order of medications a couple weeks ago--many thanks to Emily (the pharmacist I work with) who graciously put in extra hours at work ordering and organizing the medications.

This first order of medications was carried into Haiti this past Monday by teams visiting Haiti from Minnesota. After a small decrease in cholera cases last week, RHFH is unfortunately seeing an increase again, with 73 patients in the cholera house last night, so the medications will be immediately used to save lives. You can read Licia's most recent update here and see pictures of the medications in Cazale. NPR also recently posted this article describing the current situation with cholera in Haiti.

I will be purchasing more cholera medications this coming week. Like I've said before, most of the medications and supplies that are needed to treat cholera can be either purchased in Haiti, or Lori and Licia can find organizations in Haiti that are giving away donated items. However, there are a few medications that are either very expensive to purchase in Haiti, or are unavailable or very difficult to find in large quantities. These are the medications I purchase here.

None of this would be possible without the support of everyone who has donated money, my friends at Haiti Mission Project who do the administrative behind-the scenes work to process donations, the pharmacists I work with who generously donate their time and expertise, the teams and individuals who carry medications to Haiti in their luggage, and of course everyone on the ground in Cazale.

Thanks again for your generosity! This need will be ongoing for as long as there is cholera in Haiti--please watch my blog for updates.

Cholera medication update (& how you can help)--UPDATED

2011-06-23T16:37:00.011-05:00

3rd UPDATE (Saturday 7/2): We've raised a total of $3125!! Thanks to your generosity, the cholera medications will be on their way to Haiti very soon. Please continue to donate if you are able to--as long as cholera is in Haiti, there will be an ongoing need for cholera medications and supplies.

2nd UPDATE (Saturday evening 6/25): We've raised $2040 so far! Thanks so much to everyone who's donated and to those who are re-posting to help spread the word. Please continue to donate if you are able to so we can meet this need for Real Hope for Haiti. Please contact me with any questions (jenniferhalverson09 AT gmail DOT com).

1st UPDATE (Friday afternoon 6/24): Please see Licia's post from today here. I am going out on a limb and will be purchasing another ~$2500 worth of medications to be sent to Haiti ASAP. I don't have the funds for these meds yet but am trusting they will come in. Please help if you can! See below for information on how to donate. Thanks.

Thank you to everyone who has already donated money and supplies to help treat cholera in Haiti!

The 2nd "wave" of cholera in Haiti is just as bad as the first, if not worse. I continue to stay in contact with my friends at Real Hope for Haiti. They are tired and their incredible Haitian workers are tired, but every day & night their works continues and they continue to save hundreds of lives.

Please go here to read Licia's update from today. Here is an excerpt:

We do a bed count each evening at the cholera house. This week we had the highest 87 patients sleeping at the house. 59 of those were on IV’s and 28 were drinking ORS. Each of these patients has a caregiver that is sleeping in a chair by them. Now there are a few families that might have 2 or 3 kids there and they just have one care giver. We has to send 10 people home that did not live far away. They were drinking ORS and were not that bad. We told them to come back in the night if they got worse. We did not have an empty chair or even a cement block for people to sit on.

Most of the supplies and medications needed to treat cholera can be obtained in Haiti (either via donations or by purchasing). There are a couple medications that are easier to find (or cheaper to purchase) here in the U.S. I just placed a $900 medication order that I will be picking up in a few days, and sending to Haiti next week. About $700 of the order is medications for cholera. The remaining $200 of the order is miscellaneous medications (for burns, respiratory illnesses, etc) that will be given to both Real Hope for Haiti and to Heartline.

I still have about $800 in the medication account so I'll be able to pay for most of this order with donated funds. However, as I've written before, cholera is not going away anytime soon, so please continue to donate if you are able to. I anticipate that I'll be placing medication orders every month for the indefinite future. The more donated funds I have in the medication account, the more I'll be able to purchase.

I continue to work with Haiti Mission Project to collect monetary donations. To donate online using Paypal, please go HERE and click on the 2nd yellow "Donate" button. If you'd like to donate by check, please indicate in the memo section that your donation is for "medications for Haiti". As always, 100% of all donations are used to purchase medications (and occasionally medical supplies), and all donations are tax-deductible. Tax donation receipts are provided at the end of the year.

Please see this post for more details about donating supplies. They are especially in need of 22 and 24 gauge IV catheters and "microdrip" IV tubing. If you are in Haiti and have access to these supplies, please contact Licia (Licia AT realhopeforhaiti DOT org). If you are in the U.S. and have access to these supplies, please contact me at jenniferhalverson09 AT gmail DOT com

With the right medications, supplies, and (especially) personnel, cholera can be successfully treated.

Please e-mail me with any questions.

Thank you again for your generosity!
Jen

More suffering (updated)

2011-06-07T00:44:00.016-05:00

Tonight, my heart is hurting for a country I love. I was in Haiti for most of the month of May--I came back to the U.S. on 5/31. I'll be here in the U.S. for most of the summer before heading back to Haiti in August. Tonight I am feeling helpless as I read Twitter and Facebook status updates such as these:

Michel Martelly: (Haiti's new president):
"Prezidan an ak tout ekip ijans li an ap travay tout lannwit pou vini an èd a moun ki viktim nan gwo lapli aswè a."
Translation: "The president with all of his emergency teams are working all night to come to the aid of the victims of the heavy rains tonight"

P.J. Pitts (pharmacist currently living in Port):
"Massive mudslide between Petionville and Rou Frere, homes buried with people inside. First corpse found minutes ago. *sighing* it's going to be a LONG night..."

"got a call from Billy's girl - houses collapsed in a mudslide from the storm, she hears screams from inside. Our guys are on their way to check it out. Hoping the screaming is from the thunder and lightning, not people trapped."

"recovered 3 bodies, no signs of survivors. Hand clearing ruble from a steep ravine, no way to get machinery in there..."

"just got word that a woman was pulled out of the slide - being transported to the hospital now - first news of a survivor to be pulled from the rubble and debris!"

"Normally rain washes things away; the air smells clean and fresh when it rains. Not this morning. This morning it smells putrid - like the sludge that forms at the bottom of a pond as living matter is decaying - it's as if the rain and mud slides is dredging up more than just memories of the earthquake."

"two women (late teens/early 20s) taken to the hospital with injuries sustained from the landslide - one with a 5-7" laceration approx. 1" deep on her leg and the other was hit pretty badly in the back of the head by falling debris. No survivors pulled out of the slide itself thus far. Time for a nap, then back to hopefully change that."

"Back at the house - guys are passed out, I'm tracking down a few leads on cadaver dogs. The area we were at was very unstable - the guys had to use climbing gear and repel down the mudslide to dig and recover bodies. I'm not sure how they're going to manage body recovery... The area is a freaking death trap. Areas of mud covered concrete, you take a step, then you're knee deep in quick-sand-mud."

MMRC Haiti:
"We are currently responding to a mudslide between Petionville & Rou Frere"

"So far much body recovery, still keeping hope we will find some survivors."

"Our crew is rappelling down the hill to find survivors @ the mudslide. If u are in PaP and can help please call 34387073"

"At daylight we found 2 injured girls, took them to @medishare4haiti."

"Our crew rappelled from house pile to house pile on the hill checking for survivors."

"Many people trapped in their homes, not many survivors."

I also received a forwarded e-mail from someone who has lived in Haiti for much of her life, saying these are the heaviest rains she has ever seen.

I have been in Port au Prince during massive rains. It is crazy how fast severe flooding occurs in that city. Port au Prince is almost completely deforested, has essentially no functioning storm sewer system, and has hundreds of thousands of people living right at sea level, with the city rising sharply upwards from the sea (meaning the floods roll downhill). Not to mention the hundreds of thousands still living in tents, many precariously placed on steep hillsides.

I try not to be a pessimist when it comes to progress in Haiti, and I try to focus on the positive things that are happening there (though I'm not sure I always do a great job at this). And I know that like so many other challenges, the people of Haiti will get through this somehow.

But I am sad and I am so worried about friends and former patients who I am sure are wet and cold and scared right now. And as my friend Terri just wrote, "how much suffering can one little country bear?"

Thank you!

2011-06-06T06:00:00.005-05:00

Just over $1100 was donated to purchase medications for cholera. The stellar pharmacist I work with (Emily) ordered meds and I picked up some of them on Saturday. I will be picking up the rest later this week. The first of the meds are on their way to Haiti today (thanks Jeff!), and the rest should be there sometime in the next couple weeks.

This need is ongoing--cholera is not going away anytime soon--so please continue to donate if you are able to. To donate, see this post for details or click here to donate (click on the 2nd Paypal button). With the right medications, supplies, and (especially) personnel, cholera can be successfully treated.

Thank you again for your generosity!
Jen

Cholera--how you can help (updated)

2011-06-01T19:43:00.015-05:00

There isn't much being written about cholera in Haiti right now (at least when compared to last fall when the outbreak started), but the articles that are being written are reporting that cholera cases are rapidly rising all over Haiti and the Dominican Republic. My friends at Real Hope for Haiti (RHFH) in Cazale are seeing a huge surge in patients. Their cholera treatment center has 25 beds. This morning they had 70 patients. Despite this, they have not had to turn anyone away and they want to keep it that way. They are working extremely hard and are "degage-ing" (kreyol word for "making it work").

Please read updates from Real Hope for Haiti here (from May 30th) and here (from May 31st) and here (from June 1st).

Here are their Facebook/Twitter updates from the past 24 hours:
Saturday (5/28):
"29 pts sleeping in the cholera house tonight. Still not enough beds for all the people, but getting by the best we can. New pts in for today lower than the last few days. No RC kids sick yet. No deaths in this latest surge. Big rain tonight could mean trouble in a couple of days though. Thanks for your prayers."

Sunday (5/29):
"36 people at the cholera house--this is the highest number we have ever had at night. Highest ever. Pray...we are trying to hire new staff today to help with the increase in patients."

Monday (5/30):
"Cholera- several brought again on doors today. One man came in-he did not apprear to be breathing. Staff put her head to his heart-still beating. IV's started right there by the gate. After 2 hours he is still not "awake" but we can see him breathing. Thank you Jesus for life today."

"Sad stories and amazing survivial at the cholera house today. IF Lori and I have time will get a post up tonight. Help needed with a few small items."

"49 at the cholera house tonight. 49-we have 25 beds."

Tuesday (5/31):
"53 people at cholera house tonight. There were 21 people that were release today as they have recovered. 25 new admits today."

"There are 25 beds in the cholera house. The rest of the people sitting in chairs. Tonight we ran out of chairs. We are currently taking the chairs from our house up tonight for those ill to sit in. Tomorrow we will be adding chairs to out list."

"53 to 60 at the cholera house."

Wednesday (6/1):
"Working hard all morning getting the cholera house organized. There were around 70 patients there this AM. We are trying to get a large tent set up this afternoon."

"65 patients at the cholera house tonight."

Thursday (6/2):
"Update on Cholera house this evening. 67 patients~~41 on IV fluids and 26 on ORS. It has been raining in Cazale since yesterday afternoon so we know there are many that could not make it down the muddy mountains trails."

Check out this graph showing the recent dramatic increase in cases:

(graph made by Lori Moise, from Real Hope for Haiti website)

I have visited RHFH's cholera treatment center many times. I have been helping to supply them with medications and supplies since the outbreak started. I have said this many times before but it needs to be said again--they are the real deal. They treat everyone who comes to their treatment center. They do not charge anyone to be treated. In the midst of this epidemic, RHFH has hired many people and is providing much-needed jobs in the community. Their staff is compassionate and they are very, very skilled at treating cholera. They keep their treatment center clean. Patients are given gowns and hygiene products. Every patient is educated on how to prevent the transmission of cholera and is provided with supplies (such as bleach powder and oral rehydration salts) when they are discharged.

The reason they are seeing so many more cases is likely 3-fold:
1. It is the rainy season in Haiti. More rain = more contamination of rivers and other water sources, which means more cholera.
2. "Word of mouth" (I think the word in Kreyol is teledjol) is huge in Haiti. The word on the street is that if you make it to Real Hope for Haiti's cholera treatment center, you will survive. They are also known as being a place where patients are treated well.
3. Other cholera treatment centers in the area have either closed, or are now charging upwards of $250 Haitian (about $30 U.S.) to be treated. That is prohibitively expensive for the average Haitian person.

Real Hope for Haiti has treated almost 1700 patients since the outbreak started. They have had 4 deaths, which is a 0.2% mortality rate. Every death is tragic. At the same time, that low of a mortality rate is almost unheard of in a cholera epidemic. And each of the 4 who died had other significant co-morbidities that made them more susceptible to dying from cholera.

Like I said--they are the REAL DEAL. I want us to do everything we can to support them. I am working to connect them to people and organizations in Haiti that can donate much-needed supplies and medications directly to them.

If you are in Haiti and have access to the following supplies, please contact me (jenniferhalverson09 AT gmail DOT com) or contact RHFH directly (lori AT realhopeforhaiti DOT org):
1. IV catheters (22 gauge and 24 gauge)
2. Microdrip IV tubing (60 drips per mL)
3. Diapers in all sizes (babies to adult)
4. Cots
5. Buckets
6. Large trash bags

If you are not in Haiti, I am again collecting donations to purchase medications and supplies for RHFH. I have networked with other organizations to get the meds/supplies to Haiti ASAP. There are teams (working with various other organizations) leaving from Minnesota almost every week. The first shipment of meds should go out this coming Monday. I will be buying Azithromycin suspension, which is used to treat children under 8 years of age with cholera. Only one dose is required for treatment. Each bottle costs a little over $10, and each bottle can treat anywhere from 3-12 children, depending on their weight. Funds may also be used to purchase medical supplies or other cholera medications as needed.

I am again working with Haiti Mission Project to collect donations. Please go HERE and click on the 2nd donate button. As always, 100% of all donations are used to purchase medications and medical supplies, and all donations are tax-deductible. Tax donation receipts are provided at the end of the year.

Thanks in advance for your help!

(picture from Real Hope for Haiti website)

Thanks!

2011-05-11T06:30:00.002-05:00

This past weekend I had the privilege of meeting my cousin's daughter Talia for the first time. She and her brownie troop raised money for Heartline Field Hospital last year after the earthquake. They had a bake sale and sold stuff at the local ski hill. It was so fun to meet Talia!

Many thanks to Talia & Brownie Troop 411~your gifts of time and money made a huge difference in the lives of many!

Mama Emmanuel and Ti Manno...Nou sonje 'w!

2011-04-27T17:56:00.003-05:00

I think I can safely say that Ti Manno was a favorite patient of almost every volunteer who came through Heartline Field Hospital last year--and his amazing mom was loved by everyone as well. Here are a couple fun videos from July, 2010:

Update on medication project

2011-04-25T06:00:00.009-05:00

Hi everyone,
Thanks so much for responding to my request for monetary donations to buy medications. So far, we have raised $4417! (as of May 2nd). I'm so grateful for your generosity--thank you! I have a big list of medications to buy, and the more I can bring, the better, so please give if you can and pass this on. All monetary donations should be made to Haiti Mission Project (HMP). You can find donation information here (please click on the 2nd "Donate" button on this page to make sure your donation is specifically used to purchase medications). If you donate by check, please specify in the memo section of your check that your contribution is for "medications for Haiti".

Every cent of donated money goes towards purchasing medications (and likely towards purchasing a few much-needed cholera supplies as well, such as IV catheters). As a reminder, HMP is a 501(c)(3) non-profit organization based in Minnesota. Every donation is tax-deductible and you will receive a receipt for tax purposes. One of HMP's main goals is to help other organizations that are on-the-ground serving in Haiti, so they are a great partner for this project (since purchased medications will be donated to several organizations).

I am meeting with a pharmacist later today to price out all of the medications and I will place the medication order later this week. This pharmacist is someone who has been instrumental in helping me/us purchase medications over the past 15+ months since the earthquake. She does all of the behind-the-scenes work to get the meds purchased--she has spent hours and hours researching medications, finding the lowest prices possible, placing medication orders, exchanging many e-mails back and forth with me while we finalize the orders, receiving and organizing the ordered medications, and helping me arrange times to pick up the meds from the hospital. She also is a great help when I have questions related to medication reconstitution (for IV meds), dosing, and so on. She does all of this on her own time. Thanks E!

Speaking of pharmacists, there are 2 others I want to mention as well. Another pharmacist I work with, M, has graciously assisted me by e-mail in regards to medication-related questions when I'm in Haiti. She was especially instrumental in helping Lori and I figure out a pain management plan for Claudette. Finally, PJ, a long-termer in Haiti since the earthquake, is another pharmacist who has been a wonderful help with a variety of questions and has also assisted Heartline with various medications.

So in addition to being an update on medication fundraising, this post is also a shout-out to my wonderful pharmacist friends. The majority of the work they do is behind-the-scenes, but they play such a vital role in patient care. A huge MESI (thanks!) to all of the pharmacists who've helped out in Haiti, either in person or from afar.

Ti Manno, taken in Petit Goave, Haiti, January 2011
(photo credit: Beth McHoul)

Help me purchase medications & medical supplies

2011-04-20T19:50:00.008-05:00

(please read an update on fundraising efforts here)

I spent 2 wonderful months in Haiti back in January and February. As time goes on, I see my role in Haiti being shaped and formed in a few different ways. I continue to work closely with Heartline ministries, providing medical care both in person and medical advice from afar (when I'm in Minnesota). I've also had the privilege of working with Real Hope for Haiti in rural Cazale, both by providing hands-on care when I'm in Haiti and also by offering support and advice by e-mail when I'm in Minnesota. Additionally, I've connected with a few other medical providers and organizations and have been able to bring needed medications and supplies to them.

I'm planning on returning to Haiti in May for at least a short period of time (and hopefully for a little longer if I can finish up a few projects before then). I will be purchasing prescription medications for each of the organizations named above and also for at least one other medical provider working in Haiti (Dr. Megan Coffee who works with HIV and TB patients at HUEH in Port au Prince). I will also be purchasing a few medical supplies (IV catheters, pill boxes, IV arm boards for children, and IV "heplock" tubing--all things that are currently needed by these 3 organizations).

I'm able to purchase medications "at cost", meaning I get the best deal possible. Most of the medications I purchase are ones that either can't be purchased in Haiti, or are difficult to find (at least in larger quantities), or are very expensive to purchase in Haiti. Because I'm in close contact with these organizations, I purchase only medications that are truly needed, meaning nothing is wasted. So far I have $800 to work with, thanks to the generous donation of one family. Can you help me purchase more? Every cent of donated money goes towards purchasing medications and supplies--there is no overhead at all.

I am partnering with Haiti Mission Project, a 501(c)(3) non-profit organization based in Minnesota, to collect donations for this project. If you would like to contribute, please make a donation to Haiti Mission Project either online or by mail. Information and links for how to donate are here (please click on the 2nd "Donate" button on this page to make sure your donation is specifically used to purchase medications). If you donate by check, please specify in the memo section of your check that your contribution is for "medications for Haiti".

Thanks in advance--this is a great way to tangibly help people in Haiti.

Here are a few examples of how medications previously purchased with donated funds have helped in Haiti over the past 15 months (IV=intravenous, PO=oral, IM=intramuscular injection):

1. Treatment of cholera (IV and PO Zofran to treat nausea and vomiting, PO Azithromycin in both pill and suspension form for kids, PO Zinc supplements, IV fluids).

Child with cholera in rural Cazale (picture from Real Hope for Haiti)

2. Providing sedation for painful procedures in children and adults, typically wound debridement and burn debridement/dressing changes (IV/IM Ketamine, IV Propofol).

Sedation medications drawn up, labeled, and ready to be given, January 2010

3. Treatment of infants and children with sepsis and other serious infections, such as typhoid fever (IV Ampicillin, Gentamicin, and Ceftriaxone).

A baby with sepsis who was treated with donated antibiotics, February 2010

4. Treatment of adults with various infectious diseases and associated conditions (IV steroids such as Dexamethasone, IV and PO Zofran to treat nausea and vomiting that commonly afflicts those needing to take a lot of medications together, and IV medications such as Ceftriaxone, Zosyn, Clindamycin, and others).

5. Treatment of women with high-risk pregnancies (IV magnesium sulfate to prevent seizures in women with pre-eclampsia, IM steroids to help with fetal lung development, IV Penicillin G to prevent group B strep infections in newborns, IV anti-hypertensives such as Labetalol to treat pregnancy-induced hypertension during labor, IM Ceftriaxone to treat gonorrhea, IV Clindamycin, Ampicillin, and Gentamicin to treat post-partum uterine infections and post C-section wound infections).

6. Treatment of various wound and soft tissue infections encountered after the earthquake (PO antibiotics such as Augmentin, Clindamycin, Bactrim, and various cephalosporins, and IV antibiotics such as Ceftriaxone, Clindamycin, Zosyn, and others).

Makeshift pharmacy, January 2010

one year ago today...January 19th

2011-01-19T15:22:00.006-06:00

I'm not sure how long I'm going to continue these posts....another couple days maybe. I like the idea of looking back, reflecting, remembering.

You can read what I wrote one year ago today here.

Within a few hours of our clinic opening on January 18th, we realized we would need an inpatient ward. Many people's injuries were too severe to send them "home", especially when "home" was a ragged tarp stretched between 2 trees (or worse). We quickly decided to keep patients at the clinic overnight that first night, but by the second day, as we collected more and more patients, we knew we'd need a better solution. We decided to convert the former Heartline boy's home (for boys waiting for their adoptions to be completed) to a hospital. Because I was so busy in the clinic/ER/OR house, I didn't know much of what was going on at the newly-established hospital. Many of our volunteer staff stepped up and agreed to work nights to help cover all of the shifts. Coordinating the logistics of providing medical care at 2 separate sites (even though they were only separated by one street) was challenging, but we made it work, and over time, we got better at it.

We didn't have much morphine in those early days, but thanks to visiting anesthesiologists (Dr. Tami and Dr. Steve), we had a LOT of ketamine. And we put it to good use. Everyone who underwent a painful procedure was given some sort of anesthesia, usually ketamine. Ketamine is a wonderful medication--it has anesthetic, analgesic, and amnestic properties, and is very safe to use in basically anyone. It felt like a little bit of justice to be able to provide proper anesthesia to people when performing painful procedures. Most had already experienced terrible pain. Some had already undergone horribly painful procedures without any pain medications. But we were able to tell them that it wasn't going to hurt this time. And that was very gratifying.

While re-reading my post from a year ago, I was remembering some of the children we treated who seemed to not feel as much pain as we expected they would. It is a sad reality that the psychological trauma experienced by these children had already had an effect on their physical health and neurologic response to pain by the time we saw them one week later.

Back to 2011...It's been a privilege to work with Lori and Licia and many of their Haitian staff at Real Hope for Haiti this week. I hope to get out here again next week. Tomorrow I head back into Port for the weekend. I'm looking forward to seeing my friends the Ericksons who work with Providence (an organization I'm also involved with). Also looking forward to hopefully having some fun in the water this weekend if a few things fall into place. The type of water (salt water versus chlorine) remains to be seen and kind of depends on whether or not Duvalier behaves himself.

one year ago today...January 18th

2011-01-18T21:30:00.000-06:00

I remember my first days in Haiti with pretty vivid clarity. I think it is a combination of being part of something very intense, plus having my journal and many pictures to remind me of specific things that happened and specific patients we treated.

One year ago today, on January 18th, 2010, Heartline clinic opened. It was 6 days after the earthquake. A few days prior to the clinic opening, a couple of our guards who reside in a neighborhood called Simon Pele had asked us to help the people who live there. Various Heartline people visited Simon Pele to get a sense of exactly what the needs were. The medical needs were huge before the earthquake. After the quake they were even bigger. Family members of the injured placed many of them in big open areas (such as church courtyards) because there was no where else for them to go. Many people had tried to seek care at various hospitals and clinics, but most medical facilities were already overwhelmed and nothing could be done.

On that first day, we saw patient after patient who had had no care until that point except very basic first aid. And these patients didn't have cuts and bruises--they had open fractures, major closed fractures (such as pelvic and vertebral fractures), traumatic amputations, major lacerations, gangrenous open wounds, crush injuries, and open skull fractures. I've said this 100s of times in the past year, but I'll say it again--I can not imagine living for 6 days (and for some people, much longer) with these types of injuries, with little food or water, no pain medicine, likely living under a tarp (if you're lucky) or more likely sleeping under the sun and stars. Can you imagine? Up until January 2010, I'd rarely (if ever) seen traumatic wounds that had been left untreated for days or weeks. Since then, it's been a different story.

Heartline had purchased a large Canter-type truck just before the earthquake, with the idea that it would be used to transport teams and other big things. Little did everyone know that it would be used to transport hundreds and hundreds of patients injured in the earthquake. Because Hearline is located about 4 miles from Simon Pele (and many other neighborhoods in which the injured were in need of care), we went to the injured (instead of expecting the injured to come to us). We were lucky, in a way, because this allowed us to operate out of a relatively safe neighborhood that had sustained less damage than many other areas (though still had many houses that had fallen down completely). Working within Simon Pele and Cite Soleil and Aviation (Sou Piste) and other places would have been much harder logistically than working out of Heartline's various houses in Tabarre. That truck went back and forth, several times a day, picking up new patients and dropping off previously-treated patients, over and over again, starting early in the morning and finishing after dark. The drivers never got much recognition for what they were doing, but their role in our clinic was just as important as the medical providers.

You can read what I wrote on January 17th, 2010, here and what I wrote on January 18th, 2010 here.

Yesterday in Cazale I'm pretty sure we saw a guy with cutaneous leishmaniasis. As far as I know, there isn't any leishmaniasis in Haiti, but there have been cases in the Dominican Republic, and this man had (interestingly) traveled to French Guyana. There is actually a strain of cutaneous leishmaniasis that was (I believe, but don't quote me on this) initially discovered French Guyana, called Leishmania guyanensis. Treatment is typically with medications that are very difficult to track down, but after talking with P.J., an awesome pharmacist who's been working with Project Medishare for the past year, I think we figured out a way to treat him here using heat therapy. We'll see.

There is a 10 year old girl here with severe burns. With the guidance of Mary, another awesome pharmacist who works at Children's in St. Paul, we've been sedating her with "Ketafol" (ketamine plus propofol) and it's been working great. Prior to this they were using plain ketamine which was also working well. Being able to use anesthesia meds is such a blessing, as they are not always available here, and her daily dressing changes are extremely painful. It is a really tough situation for this brave girl but she is being taken care of so well here.

It's old news by now that Duvalier was arrested at Hotel Karibe today, brought to a courthouse, then released again. I'm not in Port au Prince so aside from what the updates I'm reading on Twitter and Facebook, I don't really know what's going on there. Politically-speaking, everything is quiet here in Cazale.

On a totally unrelated note, I've been listening to a lot of U2 recently. They are hands-down one of the best bands ever. And on that note, good night.

anyone know what this med is?

2011-01-18T20:39:00.001-06:00

UPDATE: friends on Facebook figured it out--it's Russian IV metronidazole. Thanks!

Can anyone tell me what this is? As far as I can tell, it is some sort of IV medication (and I believe the concentration is 500 mg per 100 mL), but beyond that, I have no idea. I don't know what language this is, either. I don't want to throw it away if it's something useful.

one year ago today...January 17th

2011-01-17T21:13:00.004-06:00

January 17, 2010: I arrived back in Haiti. Tired. Relieved. And ready to get started. I had no idea what the next year would hold.

The little plane landed on Port au Prince's only runway, then quickly taxied off onto the grass. I got out when the propellers were still spinning. The pilot unloaded my bags (just 50 pounds total--that's all we could bring--the rest of the meds & supplies had landed on Heartline's chartered plane a couple hours earlier). I grabbed my stuff and looked around. The area surrounding the airport runway was crowded with people (people associated with the U.S. military and NGOs and various governmental organizations) and aircraft, including several very large planes (C-130s, I believe). Because I wasn't sure what else to do, I started walking across the grass towards the damaged airport. I got to the edge of the grass where it turns to pavement and wasn't sure if I was allowed to cross. I waved down a very-young appearing U.S. military guy who was riding around on a 4-wheeler. I asked him if I could cross the pavement to get to the airport. He answered, "Sure, just don't get hit by an airplane." Awesome. That made me laugh. Degage. I did look carefully before I crossed--there were planes everywhere, including, off to the right, a plane taxiing down the pavement I needed to cross overy.

After crossing over I saw a long line of people. I later learned they were all waiting to leave on the next available plane, trying to get out as quick as possible. I believe this option was only open to those with U.S. passports. I then saw Troy and he lead me through the damaged airport. I saw the telltale cracks that indicated earthquake damage for the first time. I think I could have walked through the airport without showing my passport but I asked the guy to stamp it anyways--I guess to create some sort of record that I was here on this day, and also because I didn't know how long I'd be staying or if the immigration people would be as lax when I left again.

After walking through the airport we emerged outside on the other side. Things looked about the same at first, then the damage became more apparent as we drove away from the airport towards Tabarre. There were some collapsed buildings and many collapsed concrete walls. I kept thinking about how much diesel it took to get me from the airport and I felt bad. I knew that Heartline, like most of the rest of the country, didn't have a source of diesel yet. We arrived at the Livesay's house and it was so, so good to see Tara and Geronne and the kids who were still in Haiti.

That afternoon we drove around Port au Prince (including downtown) and saw some of the areas with the worst damage. It was shocking to see this country I love in a state I never could have imagined it would be in. Chan Mars, an area very near to the palace that used to be a big park, was already full of tents and tarps and other makeshift dwellings.

That evening we unpacked bags and set up our field clinic/ER/OR in the Heartline women's program/sewing program house. We sort of had a blank slate--we had several almost-empty rooms and tons of meds and supplies with which to fill them. The Heartline people who were in Haiti for the earthquake had been working long hours to get the house ready. I'm an organizer so I liked the idea of having first shot at deciding where things would go. We prepared as much as we could that evening, knowing that the next day would bring huge challenges as we opened our little clinic.

one year ago, one year later

2011-01-15T08:15:00.005-06:00

Like many others deeply involved in Haiti, I've been spending the days since the 1 year anniversary of the earthquake thinking back to what I was doing, thinking, and feeling exactly a year ago--on the 13th, 14th, 15th, and so on. I remember continuing to stare at CNN many hours a day, watching as the same footage played over and over again. I think I watched Sanjay Gupta's interview of president Rene Preval at the airport 10 or 15 times, and each time it still made me shake my head in disbelief (if you know which interview I'm referring to, I'm guessing you might have had the same response). Video footage from the grounds of General Hospital, the mass burial sites at Titanyen, and the streets of downtown Port au Prince is etched in my mind as clear as if I'd seen it yesterday. I can still hear Anderson Cooper's voice as he reported from these places. I refreshed Google Reader every few minutes, hoping for more news from those already in Haiti.

By one year ago today I was in touch with Beth McHoul and the Livesays and others, making plans to work with Heartline. I went to a meeting midday on the 15th and was discouraged by people who were saying that no one should go to Haiti right now, even medical providers, due to the logistical challenges of housing and feeding more people on the ground. Friends in Haiti were telling me otherwise, though, and by the evening of the 15th, I had a lead on a flight into Haiti with an organization called Clean the World. By early morning on the 16th, I'd made a reservation to fly to Orlando, slept a few hours, did some major food/supply shopping at Target with Marcia, stopped by the hospital I work at in the Twin Cities (Children's) to pick up medical supplies (major props to them for donating to us), and then came home to 4 bags packed and ready to go (thanks to my mom and dad and Greg E.). We left for the airport and I arrived in Orlando later that evening, one step closer to Haiti. At that point I was starting to think I might actually make it in to Haiti...but still not getting my hopes up.

Tonight on January 16, 2011, I am in Cazale at Real Hope for Haiti. I'll be here for a few days. I'm looking forward to helping out in any way I can with their clinics and cholera treatment center.

And just when we thought life here couldn't get any weirder...about an hour ago Twitter exploded with people reporting that Jean-Claude "Baby Doc" Duvalier was on a plane on his way back to Haiti. Soon after that his plane landed, and he is now apparently being driven down Route Frere, waving to people out of the window as he passes by. Others are saying there are rumors that Aristide's Haitian passport has been renewed. All of this while the most recent election's results are still very disputed. Things could get really interesting.

Update on Amanda

2011-01-14T07:24:00.005-06:00

Thank you to everyone who has prayed and hoped and given of your time and money to help Amanda this past year. What a year it has been for her. You can read more of her story here and here. Since I last posted, we spend three long (but very productive days) with Amanda while she underwent lots of various tests and procedures. We found out that Amanda's injuries to the nerves in her arm were just as severe (if not more severe) than we expected. During those three days of testing, several people generously provided housing and meals for us. They made us feel totally at home.

In early September, Amanda had major brachial plexus surgery to repair damage done when her house fell on her during the earthquake. All of the medical providers--surgeons, nurses, physical therapists, physician assistants, etc--were so kind and helpful before, during, and after her surgery. She ended up staying in the ICU for about 3 days, then spent another 2 days in the regular ward. At least one of us stayed with Amanda every night--we were back and forth from the Twin Cities many times. Again, people provided housing and meals, making the days as easy as possible on all of us.

Amanda's surgery went well and her doctors are happy with how she's doing. She still has no movement or feeling in her arm and that is completely normal at this point. Her surgeons don't expect and feeling or movement for about 6-8 months. At that point, if the surgery was successful, she will start to have some feeling and movement in her arm, and she will need to start physical therapy to retrain her brain to move her arm.

Because she's in a holding pattern right now, she came back to Haiti in early January to be with her friends and family. She'll be here for a few months, then will travel back to Minnesota sometime later this spring. Thank you again to everyone who has made this possible for her! I am especially grateful to the Mary & Tery and their whole family, Theresa & Matt, and Terri P. You guys have been amazing!

First McDonalds

At the Minnesota State Fair

Pre-surgery fun at the Minnesota State Fair--rollercoaster #1 with Laura

Rollercoaster #2 with Theresa (she loved both of them)

Looking at pics and watching video from the past year with Theresa

Last day in the hospital

23rd birthday (she received lots and lots of warm weather clothes to prepare her for winter in Minnesota)

23rd birthday--with Vicki, Jo, me, and Laura

Back in Haiti--January 2011--with Laura, Jo, me, Matt, and Theresa

Haiti One Year Later

2011-01-12T09:02:00.007-06:00

January 12, 2011: I am back in in Haiti, a place I love and consider a second home. It has been one year since the earthquake--one of the worst natural disasters ever in regards to loss of life--struck this beautiful country. This is a country I've been visiting a couple times a year since 1998. I had the privilege of living here for 9 months in 2007-08. Many of my close friends live here.

I wasn't in Haiti for the earthquake itself. I was at one of the hospitals I work at in Minnesota when I found out. I received an e-mail on my phone from Tara saying that their family was okay but everyone was scared. She mentioned that they were continuing to have frequent aftershocks. I had to read the e-mail a few times before I realized she was talking about an earthquake.

It seems ridiculous now, but at the time, I had no idea that Haiti sits on a fault line. I had no idea that other huge quakes had destroyed Port au Prince hundreds of years ago. I opened up CNN.com and saw the first reports. And I felt completely helpless. I called a few of my close friends in the states. We didn't yet know if our friends who live in Les Cayes were okay (we found out later that they were). None of us realized the extent of the disaster at that point. We had lots of questions and no answers.

I worked my ER shift that night but was distracted the whole time. I'd asked my friends to text me updates throughout the night, and they did. That night while at work I learned that the palace and Caribbean market had collapsed. Learning about those two places collapsing was the first indication to me of how bad it was in Haiti. I went home and watched CNN all night. It didn't matter that I was watching the same reports and the same limited video footage repeating over and over again. Like everyone else I was hungry for information.

I slept very little that night, and very little in the coming days. I felt helpless as I attempted to figure out if I should go to Haiti, and if so, how I would get there. All commercial flights were cancelled indefinitely. The next few days consisted of working a couple more ER shifts, exchanging lots of e-mails and phone calls with people associated with Haiti, watching lots of CNN, and many trips to Target to buy food and supplies. On the 15th and 16th plans came together to get to Haiti to work with Heartline. My ER colleagues graciously covered my shifts so I could go. I made a reservation early in the morning on the 16th to fly to Orlando later that same day. After landing in Orlando I met up with a retired Air Force doctor and together we drove to Fort Lauderdale (that wasn't the initial plan...but for the first time of many, many times, plans changed and we adapted).

At that point I hadn't slept much in 5 days, maybe 15 hours total. We arrived in Fort Lauderdale at about 3 AM, pulling a trailer filled with 1500 pounds of medical supplies. We met up with Beth McHoul and others associated with Heartline, as well as several other medical providers who would be traveling with us. From 3 AM to 5 AM, we sorted through the 1500 pounds of supplies we had, along with the 1000s of pounds of food and supplies already at the house. Heartline was chartering a 12-seat plane out of Fort Lauderdale that was scheduled to leave around 7 AM. We could load exactly 4500 pounds onto the plane (including people, personal bags, food, medical supplies, etc). Someone took out a little notebook and wrote 4500 at the top. We subtracted the weight of the people flying. We then started subtracting from the number as we added stuff to the trailer. Making decisions about what was most important, at 4 AM, after driving all night on no sleep was hard. For the first time since the quake I felt emotional. What was more important: MREs or IV fluids? Floodlights or antibiotics? Batteries or syringes? We needed all of it, and more. Difficult decisions were made. Many more would be made in the coming days and weeks.

With exactly 4500 pounds accounted for, we left for the little airport in Fort Lauderdale. We loaded up the plane with boxes, bags, and people. The pilot was given clearance to take off. That in itself was a big deal, as up until that point, their flight had been delayed several times due to airline traffic in Port au Prince. I and the Air Force doctor left for a little airport in Boca Raton and boarded a small plane a couple hours later.

Arriving in Haiti on the morning of January 17th, I felt very relieved to finally be there. Until the plane actually touched down I was uncertain I'd make it in that day. Planes were being turned around even once they were over Port au Prince. I know this is going to sound crazy to most people, but not being in Haiti on January 12, 2010, was one of the more difficult things about this past year. I'm not some adrenaline junkie or disaster chaser, but I wish I had been here. I hated feeling helpless being stuck in Minnesota. This is going to sound strange as well, but I still fear that another big earthquake will happen and I won't be here. Not because I want to be in a big earthquake, but because I fear being away from a place I love and I really don't want to experience that absolutely helpless feeling again.

The next 10 months were a blur of activity. The first few months were intense and were the busiest months of my life. We saw people dealing with incredible physical and emotional pain. While not experiencing the physical pain ourselves, we found that it took an emotional toll on us as we witnessed it over and over again around the clock. Over the months that followed, we witnessed ongoing grief along with many moments of hope and triumph: large gaping wounds that finally healed after months of intense wound care, patients walking for the first time, children getting out of bed and playing again, patients sharing their stories with each other and finding healing in each other's words and actions. It was incredibly moving to be a part of these events.

When I hear that "230,000 people died", that is difficult for me to really comprehend. But to know the individual stories of dozens and dozens of those 230,000 is far more personal. I've told a few of the stories over the past year on this blog. Thousands and thousands of stories of people's last moments alive will never be known or told. For those who died, it seems like being buried in an unmarked grave was the rule and not the exception. I can't imagine the pain of those who never found the bodies of their loved ones, who will always wonder what happened to them.

In the midst of the ongoing grief of the hundreds of thousands of people here affected by the earthquake, life does go on. Prosthetic limbs continue to be fitted. Two soccer teams consisting entirely of amputees played at the national stadium a couple days ago. Some permanent and semi-permanent housing structures are being built. Rubble continues to be removed slowly. Many kids are back in school--we see them walking to and from school every day. The historic Iron Market was rebuilt and just re-opened recently. A sort of new normalcy has taken over the country.

I arrived back in Haiti on December 31st and will be here until the end of February. It has been emotional, healing, restful, and fun being here again. I'm staying with the Livesay family and am loving it. As we start the next year "after", I am fully aware that Haiti will never be the same, but I hope and pray for continued improvement in the lives of people affected by the quake, for ongoing physical and emotional healing, for the cholera epidemic to subside, and for a stable government to exist.

You can read more about Heartline Field Hospital here and here and here. I hope to write more of the story at some point. I still have so many stories in my head that I'd like to share. For now, here are a few videos from the past year.

Some of our first patients being transported to the USNS Navy Comfort ship

Delmas 19 area damage

Heartline Hospital church service

Heartline Hospital kids singing We are the World (all of these kids came back for our "Heartline Healed" reunion party last week and they are all doing great!)

Emmanuel walking back into the hospital for the first time on his new prosthetic leg

If you're interested, there are a lot more videos from the past year posted on my Youtube page.

Pa bliye Ayiti
Pray, hope, give

Upcoming trip and cholera-related medication/supply needs

2010-12-10T03:31:00.000-06:00

The news stories are somewhat less frequent, but cholera is still affecting most areas in Haiti. The official numbers of persons infected and number of deaths are thought to be far below the actual numbers.

Please follow @biosurveillance on Twitter, or follow their blog HERE, for very frequent updates on cholera in Haiti.

The recent post-election protests in Haiti (in response to what was likely at least a partially rigged election) add another layer of misery for people who've already been through so much this year. See this post from Tara--it echoes my current thoughts about Haiti. You can follow Dr. John Carroll on his blog for updates from a cholera treatment center in Port au Prince and the challenges he's encountering with the recent protests.

Many on Twitter are posting frequent updates about the current unrest/protests. Here are some people I've been following: @KarlJeanJeune, @emilytroutman (photographer/writer), @jacquiecharles (Miami Herald reporter) @RAMHaiti (very popular Haitian musician), @KatzOnEarth (AP reporter), @DokteCoffee (MD working at General Hospital), and @gaetantguevara.

I will be in Haiti for all of January and most of February. Part of this trip will (hopefully) be a time to relax and reconnect with people, including patients we've taken care of over the past year. I've gotten to know many of our patients well and it will be great to see them again.

A good portion of my time will be spent working with medical organizations in Port au Prince and elsewhere in the country (if the need arises). As the details are sorted out, I will update here. Most are anticipating that the cholera epidemic/outbreak will continue for several months, so I expect to be involved directly with treating cholera patients. At this point, I'm intentionally not committing to a specific organization because I want to be mobile and flexible as needs arise in various places.

Below is a list of supplies and medications that would be very useful in Haiti. I could also use monetary donations to purchase additional medications. I can buy Lactated Ringers IV fluids for a little less than $1 per liter. They're heavy (1 kg, or 2.2 pounds, per liter), but I have been sending them to Real Hope for Haiti with various people who are traveling to Haiti from Minnesota and have room in their luggage, and I'll continue to do this. Azithromycin is more expensive; thirty 500 mg tablets are $82.66 and one 30 mL bottle of Azithromycin suspension (for babies & children) is $10.92. Each bottle of Azithromycin suspension can treat about 4-6 children, depending on their weight. That is about $2 for a dose of antibiotics to treat cholera in one child. Zofran (an amazing anti-nausea/vomiting medication) costs $5.52 for 30 dissolveable tablets (about 18 cents per dose). Please contact me at halv0105 (at) umn (dot) edu if you are able to help out with medications, supplies, or monetary donations. Thanks in advance!

General supplies
1. Non-sterile gloves, sizes M and L
2. Medical-grade disinfectant wipes
3. Hand sanitizer
4. Diapers (for babies and adults) and baby wipes
5. Chux pads
6. Good quality headlamps
7. Sharpie markers
8. Baby formula (a general need not related to the cholera outbreak)

Medical supplies:
1. IV catheters: 18, 20, 22, and 24 gauge (preferably IntraCath)
2. IV tubing
3. ORS packets

Medications:
1. Doxycycline tablets
2. 1 liter bags of IV fluids (Lactated Ringers)
3. Zofran (ondansetron) IV and sublingual tabs
4. Azithromycin (tablets and oral suspension)
5. Ciprofloxacin tablets

Updated antibiotic regimens for cholera in Haiti

2010-11-04T08:52:00.004-05:00

These recommendations should be used as of October 28, 2010. They are based on local antibiotic resistance of the cholera strain currently present in Haiti.

I have ranked the antibiotic regimens in regards to ease of dosing and cost of treatment, using the CDC's website as a guide. Some recommend that antibiotics should be reserved for severe cases only. However, that approach seems to be shifting towards treating all suspected or confirmed cases, or at least all significant cases. The reason for this is because antibiotics will decrease the duration of time a cholera patient sheds cholera bacteria in their stool, thus leading to decreased transmission and ultimately to fewer cases of cholera. Consideration also should be given to the patient's home environment. If a patient with suspected or confirmed cholera lives in a home with multiple other people, especially with children or pregnant women, they should be treated. In the end, it seems prudent to treat all or most cases.

Bactrim should NOT be used. This cholera strain is resistant to Bactrim. In Haiti, Bactrim is known by many names: co-trimoxazole, trimethoprim-sulfamethoxazole, tmp/smx, Septra, and Sulfatrim. None of these should be used.

Here are the possible antibiotic regimens:

Adults--choose one of the following:

1. Doxycycline 300 mg PO once

2. Ciprofloxacin 1000 mg PO once

3. Azithromycin 1000 mg PO once

4. Erythromycin 500 mg PO 4x/day for 3 days

5. Tetracycline 500 mg PO 4x/day for 3 days

Pregnant/nursing women--choose one of the following:

1. Azithromycin 1000 mg PO once

2. Erythromycin 500 mg PO 4x/day for 3 days

3. Ciprofloxacin 1000 mg PO once (officially, Cipro is not recommended in pregnancy, but if the first 2 choices aren't available, in an epidemic setting, the benefit would likely outweigh the risk, which is small to begin with)

Children under 8 years of age--choose one of the following:

1. Azithromycin 20 mg/kg PO once

2. Erythromycin 12.5 mg/kg PO 4x/day for 3 days

3. Ciprofloxacin 20 mg/kg PO once (similar to above, Cipro is not recommended for kids, but in an epidemic setting the benefit would outweigh the risk, which is small to begin with)
4. Doxycycline 4 mg/kg PO once, up to a max of 300 mg (according to the CDC, a single dose of Doxycycline at this dose is safe for children; according to PAHO, it should be a second-line treatment and only be used if other options are not available)
5. Tetracycline 12.5 mg/kg PO 4x/day for 3 days, up to a max of 500 mg per dose (I would only recommend using Tetracycline if other options are not available)

Children 8 years of age and older, but still smaller than an adult--choose one of the following:

1. Doxycycline 4 mg/kg PO once, up to max of 300 mg

2. Azithromycin 20 mg/kg PO once, up to max of 1000 mg

3. Ciprofloxacin 20 mg/kg PO once, up to max of 1000 mg (same caveat as above)

4. Erythromycin 12.5 mg/kg PO 4x/day for 3 days, up to max of 500 mg per dose

5. Tetracycline 12.5 mg/kg PO 4x/day for 3 days, up to max of 500 mg per dose

One last side note--these are big doses of Doxycycline and they will cause nausea in most people. Try to give an anti-emetic med with the Doxy if you can.

Hurricane Tomas

2010-11-01T06:58:00.004-05:00

I know what 60 MPH winds (lasting about 60 minutes) can do to a city, trees, billboards, power lines, and tent cities. My account of the brief (and compared to a real hurricane, quite "mild") microburst storm we experienced back in late September is here.

I was also in Haiti for tropical storm Noel in October, 2007. Though only a tropical storm, the flooding it produced was devastating in many parts of the country, especially the south. I will never forget crossing a river near Cavaillon (in southern Haiti) on the way out to Les Cayes (to visit Providence House), then crossing over the same river again several days later. The river was perhaps 3-4 times as wide as it had previously been (and was much, much deeper), and everything that had been along its banks was covered in muddy water. This was only one river of many that had severely overflowed its banks.

Based on these 2 storms, I am scared for what Haiti could experience later this week from this storm. Predictions from several days out can be wrong. But if current predictions are correct, Hurricane Tomas could make landfall as a category 2 hurricane in southern Haiti, with winds of up to 110 MPH possible (and the winds certainly wouldn't last only 60 minutes this time). I am hoping and praying the predictions are wrong, and that Hurricane Tomas continues on westward over the open ocean instead of turning north towards Haiti.

FAQ---what medications & supplies are most needed?

2010-10-29T07:58:00.003-05:00

Some have asked me, "What meds and supplies are needed in Haiti to deal with the cholera outbreak?" If you are going to Haiti in the near future, here are some medications and supplies that are really needed. If you'd like to donate anything from this list, please e-mail me at halv0105 AT umn DOT edu. If you can get the items to Port au Prince, I can put you in touch with people there who will get the meds and supplies to people who need them asap.

General supplies

1. 5 gallon buckets
2. Non-sterile gloves, sizes M and L
3. Bleach, spray bottles, and paper towels
4. Medical-grade disinfectant wipes
5. Bars of soap
6. Hand sanitizer
7. Good quality gallon size Ziplock bags to make hygiene packs (or just make your own hygiene packs with a couple washcloths, a couple bars of soap, hand sanitizer, ORS packets, etc)
8. Diapers (for babies and adults) and baby wipes
9. Chux pads
10. Headlamps

Medical supplies:
1. IV catheters: 18, 20, 22, and 24 gauge
2. IV tubing
3. ORS packets

Medications:
1. Doxycycline
2. Ciprofloxacin
3. 1 liter bags of IV fluids (Lactated Ringers)
4. Zofran (ondansetron) IV and sublingual tabs
5. Azithromycin (tablets and oral suspension)

A few things to remember:
At least for now, please only donate medications and supplies that are on this list. Other meds and supplies are typically needed, but in a time when everyone is working on the cholera epidemic, sorting through extra meds and supplies will create extra work for people who are already overwhelmed and working very long days. Please do not donate used supplies or expired meds. Do not donate opened/unsealed meds (such as a personal prescription), and do not donate partially used items (such as a half-empty box of gloves, an open bottle of hand sanitizer, etc). I don't mean to sound harsh--I just know how much time it takes to sort through inappropriate donations.

Thanks in advance for your help!

estimated IV fluid needs in pediatric cholera patients

2010-10-28T02:36:00.010-05:00

Many are wondering what volume of IV fluids cholera patients will require. As my specialty is pediatrics (and pediatric emergency medicine specifically), I will comment on expected pediatric fluid requirements. Keep in mind that these are obviously estimates--but hopefully this will help people plan in advance. For info on how to actually administer the fluids (how much, how fast, etc), see my previous blog here.

According to WHO guidelines, a significantly dehydrated child with cholera will require about 200 mL/kg in the first 24 hours. This calculation includes 100 mL/kg over the first 3 hours (for children over 12 months of age), then 100 mL/kg over the ensuing 21 hours. 100 mL/kg over 21 hours ends up being about 1.25 times the normal maintenance rate. Depending on the child's stool losses, they may require more than 1.25 times the maintenance rate. For children under 12 months of age, the initial 100 mL/kg is given over 6 hours, with the next 100 mL/kg given over the ensuing 18 hours. This alters the calculations slightly, but not by much. The estimates below are based on children over 12 months of age, but they should good estimates for infants and children of all ages.

Based on these calculations (using the 4/2/1 method for calculating pediatric fluid requirements), here are expected fluid requirements for day #1 and day #2:

Child's weight---Day #1 fluids---Day #2 fluids
5 kg---------------1 L-----------------0.6 L
10 kg-------------2 L-----------------1.2 L
15 kg-------------3 L-----------------1.5 L
20 kg-------------4 L-----------------1.8 L
25 kg-------------5 L-----------------2 L
30 kg-------------6 L-----------------2.1 L
35 kg-------------7 L-----------------2.3 L
40 kg------------ 8 L---------------- 2.4 L

As for adults, I've heard estimates from 4-8 liters to 10-20 liters total per case of cholera. I would tend to lean towards the higher end of this spectrum.

Remember that lactated ringers is the preferred fluid to use in cholera. If LR is not available, 0.9% normal saline is the second choice. If using normal saline, it should be given plain for the initial rapid fluid replacement (either the first 6 hours for infants less than a year of age, or the first 3 hours for children over a year of age). You will then need to add a potassium source, either to the IV solution, or orally, as potassium depletion is severe in cholera. LR contains potassium; normal saline does not.

fluid replacement in cholera--pediatric patients--WHO guidelines

2010-10-26T12:52:00.003-05:00

Being stuck in Minnesota, I don't feel like there is much I can do, other than continue to get the word out and provide relevant medical information. It is very frustrating to not be able to be in Haiti right now, but I'll keep doing whatever I can from here. Please let me know if there are other medical cholera-related topics you'd like me to address.

The mainstay of treatment in cholera is fluid replacement, either with oral rehydration salts/solution (ORS) or IV fluids. As DokteCoffee (infectious disease MD who has been working in Haiti since January) has pointed out on Twitter: "Taking care of cholera patients is not difficult or complicated medicine. It's just a lot of work. volume resuscitation...You don't need all of the facilities of a hospital to take care of cholera. You just need the ability to give people back fluid lost."

I will divide this information about fluid replacement into pediatric and adult categories, and further into degrees of dehydration. My information sources are the WHO guidelines for the management of cholera and my own personal experience with fluid replacement in dehydrated patients. A lot of this information is taken directly from the WHO guidelines. Here are essentially the same guidelines in French. I am not trying to reinvent the wheel--I am just trying to put the information from the WHO's chart in written form, with some comments added here and there.

What I'm writing here is fairly detailed. If possible, it's worth familiarizing yourself with these guidelines now. They're a little detailed but they're not difficult. However, if you are in the midst of dealing with masses of people who need fluid resuscitation, don't get overwhelmed by the details--just give fluid fast, either IV or ORS. As I note below, for the vast majority of pediatric patients without kwashiorkor, it is hard to give too much fluid--as long as they have a healthy heart and kidneys, they will just pee out the extra fluid.

A quick assessment of the hydration status of pediatric and adult patients should take no more than a minute or two per patient, and will guide you in how best to rehydrate them. The main things to note are: ability or inability to drink, severity of vomiting, presence or absence of tears (in children), mouth (moist or dry), eyes (sunken or not), skin (whether or not the skin "tents" when pinched), quality of distal pulses (strong or weak/thready), and the overall level of consciousness (normal, lethargic, or obtunded).

ORS can be made from standard ORS packets or can be made by adding 1 teaspoon salt and 8 teaspoons sugar to a liter of water. The solution should not taste saltier than normal tears. One liter of water is 2-3 glass coke bottles depending on how big they are. If possible, have the patient eat a source of potassium, such as mashed banana. This is important as patients will lose a lot of potassium in their stool, and potassium depletion causes severe muscle cramps.

Pediatric patients:

1. Mild dehydration or no dehydration (able to drink fluids, still making tears, mouth is moist, eyes not sunken):

--These children can be treated at home as long as the family has access to a clean water source and understands how to prepare and give ORS.

--The main goal is to give ORS to replace stool losses.

----->For children under 2, this will be approximately 50-100 mL of ORS per stool, up to about 500 mL per day.

----->For children 3-10, this will be approximately 100-200 mL per stool, up to about 1000 mL (1 liter) per day.

----->Over 10 years of age, let them drink ad lib, and expect that they'll need about 1.5-2 liters per day (or possibly more) to replace stool losses.

--It's important to emphasize with families that they need to give the ORS each time a young child stools, around the clock, otherwise the child will likely become more dehydrated. The family should make up a liter of ORS and give it by syringe, spoon, or cup. Depending on how the family is going to give the ORS, you can help them figure out how much to give (i.e., how many syringes or how many spoonfuls or how much of a cup for each stool).

--Emphasize the families that they need to use clean containers, syringes, spoons, cups, etc.

2. Moderate or severe dehydration (not making tears, mouth is dry, eyes are sunken, when you pinch the skin it stays tented); the approach to rehydration (either ORS or IV) depends on how sick the child is.

--If the child can drink and is not overly lethargic or unconscious, you can start with ORS (either PO, or if the child cannot drink fast enough, it can be given NG).

--You will first need to replace the approximate volume of fluid that has already been lost. This can be calculated by assuming that the child has lost about 8-10% of the body weight. So if the child weighs 15 kg and is clinically found to be moderately dehydrated, the child has lost about 1.2-1.5 kg of body weight, or 1.2-1.5 liters (1200-1500 mL).

--You should give this initial bolus of fluid (for example, 1200-1500 mL for a 15 kg child) over the first 4 hours. Place the required amount of fluid in a clean container and instruct the parent to give the child the fluid continually, either by syringe, spoon, or cup, until all fluid is given. If the child has ongoing vomiting or is looking worse, you'll need to put in an IV and proceed as detailed below.

--If the child is able to drink the required amount of fluid in the first 4 hours, the next step is to replace ongoing stool losses, as described above under the "mild dehydration" section.

--If the child is vomiting a lot, can't drink, is lethargic, is unconscious, or has weak/thready pulses, you will need to start an IV. If this is not possible, rehydration can be started with ORS by NG tube. Infants (under 6-12 months) with any degree of dehydration other than mild will also likely need either an IV or an NG.

--Give a dose of an anti-emetic if possible, so the child will be able to start drinking ORS as soon as possible.

--Children with severe dehydration need fluid replaced quickly to avoid death. Give 30 mL per kg of either lactated ringers or normal saline IV over 30 minutes (or give the same volume of ORS by NG). Lactated ringers is preferred if available. If using normal saline, it should be given plain for the initial rapid fluid replacement (either the first 6 hours for infants less than a year of age, or the first 3 hours for children over a year of age). You will then need to add a potassium source, either to the IV solution, or orally, as potassium depletion is severe in cholera. LR contains potassium; normal saline does not.

--After the initial bolus, give another 70 mL per kg over the next 2 1/2 hours. Patients should get a total of 100 mL per kg in the first 3 hours. For kids less than a year of age, give this first initial volume (100 mL per kg) over 6 hours instead of 3 hours. Again, you can give these same volumes of fluid by giving ORS via NG tube if necessary. It will feel like you're flooding the child but this is what the child needs to restore intravascular volume.

--After the initial 100 mL per kg, start maintenance fluids, giving an additional 100 mL per kg total divided over the next 18-21 hours (depending on if the initial 100 mL per kg was given over either 3 or 6 hours). If the child continues to have lots of diarrhea, keep IV fluids at the same rate (the same rate it was running at to give 100 mL per kg over 18-21 hours) until diarrhea starts to improve. Once kids can drink, start offering ORS to replace stool output as above.

--Another way to think about it is using the traditional pediatric 4/2/1 formula. I won't get into any details about this here. If you know the 4/2/1 formula, you can use it to calculate maintenance fluids after the initial 100 mL per kg is given (over 3-6 hours depending on the patient age)--the child should be getting about 1.25 times the normal maintenance rate per hour by IV (plus ORS as tolerated).

These are guidelines---the bottom line is that the patient will need a LOT of fluid. You may not have the nursing staff to make sure people are getting these exact volumes---just make sure they're getting enough. In regards to giving too much, as long as the child isn't severely malnourished (i.e. kwashiorkor) and has a normal heart and normal kidneys (this should be the majority of kids, as presumably most kids with severe heart and kidney problems wouldn't have survived), they can handle a lot of fluid. I would err on the side of giving too much rather than giving too little.

One last point--breastfed infants should continue breastfeeding! Whatever they take in by breastfeeding is in addition to the fluid requirement detailed above.

UPDATED antibiotic recommendations

2010-10-25T23:22:00.008-05:00

UPDATED again on 11/4:
--According to the CDC website, Azithromycin and Erythromycin can be used to treat cholera in Haiti. These antibiotic choices will be particularly useful for children and pregnant/nursing women.
--Doxycycline should be dosed at 4 mg/kg, not 6 mg/kg as I had previously stated. The update posted on the CDC website is the first place I've seen an official recommendation for pediatric doxycycline dosing.
--Based on these findings, I posted a new blog with the most recent antibiotic recommendations, and have deleted this blog.

Haiti Operational Biosurveillance & cholera antibiotic resistance

2010-10-25T11:38:00.005-05:00

THIS is an incredible site to follow. They update the cholera outbreak situation frequently throughout the day with very useful information.

Through this site, I learned last night about rumors of Doxycycline resistance in the strain of cholera that is infecting people in Haiti. This morning they updated that the strain is NOT resistant to Doxycycline. The strain is, however, resistant to Bactrim. Based on this information, I have updated my previous recommendations; see the new recommendations here. The only change I made was to remove Azithromycin and Erythromycin for now, as we don't yet have susceptibility data for these 2 antibiotics. If I hear anything different, I'll update again.

UPDATE: new antibiotic recommendations are HERE--according to the CDC, Azithromycin and Erythromycin can be used to treat cholera in Haiti.

one misconception about ORS

2010-10-24T23:02:00.001-05:00

I heard from a friend (who is currently in Port au Prince) that many people are worried because they don't have access to the official ORS packets (the pre-mixed packets of salt and sugar and electrolytes that are added to a liter of water to make "serum oral", as it is known in kreyol). She asked if she should encourage people to make their own ORS using the well-circulated recipe (1 liter water + 1 tsp salt + 8 tsp sugar + a potassium source, if possible) in place of the pre-mixed ORS packets.

This is a good question, and my answer is an unequivocal YES. It is really too bad that people are getting the impression that ORS can only be made by using the pre-mixed ORS packets. Educating people on how to quickly make their own ORS is crucial to helping people survive something like cholera.

Think about it--say a child starts having severe diarrhea, and the child's mom believes she must use the pre-mixed ORS packets to make serum oral. The mom may spend a couple hours asking around before she finds a pre-mixed packet of ORS to use. By this time, her child may be so sick he can no longer drink. Then the mom must try to find a clinic to which she can bring her child, which will use up more precious time. Most patients will need to be brought to a clinic or hospital (cholera treatment centers, or CTCs, are being set up all over Port au Prince and the surrounding areas), but oral rehydration should still be started asap before transporting (and should be continued while transporting if possible).

The child's survival will depend on how much time elapses before fluid resuscitation is started. Fluid resuscitation is simply the process of giving back fluid that has been lost in the stools. One of the main goals in cholera treatment should be to start fluid resuscitation at home, as soon as symptoms start. If pre-mixed ORS packets are available, these should be used. If they are not available, ORS should be made using the recipe above.

When educating people about how to make homemade ORS, be cognizant about what resources are available to the family. One liter can usually be measured by adding 2-3 glass Coke bottles of water (depending on the size of the bottle). Most families will have access to some basic silverware. Ask to see a spoon, and use the spoon to instruct them on how much salt and sugar to add (some spoons are more like a tablespoon so they'll need to be instructed to add less than a spoonful). Remind them that the solution should be no saltier than tears. And remind families to add a potassium source (bananas are cheap and plentiful in Haiti).

My next blog will focus in-depth on pediatric fluid replacement (both IV and ORS) in cholera.

fantastic resource on breastfeeding in cholera

2010-10-24T08:15:00.006-05:00

I found this on Ruth Hersey's Facebook page. Check it out HERE.

The bottom lines:

1. As long as they are not unconscious, moms with cholera can and should still breastfeed their babies, even if the mom is receiving IV fluids. Moms and breastfeeding babies should be kept together if at all possible. Studies have shown that breastfed infants have a lower chance of developing severe cholera compared to non-breastfed infants.

2. Cholera is not transmitted in breast milk. Mom should be careful to wash her hands before breastfeeding or if touching the baby's mouth.

3. As long as the baby is well and is not showing symptoms of cholera, only the infected/sick mom needs to receive antibiotics (and not the baby). The breastfeeding mom should be given either erythromycin or azithromycin, but not doxycycline.

antiemetics in cholera--pediatric and adults doses

2010-10-23T08:20:00.001-05:00

Vomiting is a major feature of cholera. If you can effectively treat the vomiting, you may be able to treat patients with ORS instead of IV fluids.

The best antiemetic available is Zofran (ondansetron). Zofran can be expensive, but a lot of it was donated to Haiti after the earthquake so many organizations may still have access to it. Zofran is available in IV (usually 4 mg per 2 mL), PO (liquid or tablet) and sublingual (dissolvable tablet) forms. The dosing for IV and PO is the same. If you have access to the sublingual form of Zofran, it should be very useful for treating patients with cholera. Zofran is very safe and doesn't have any major side effects to worry about.

Adult dosing: 4-8 mg IV or PO every 6 hours as needed.

Pediatric dosing: 0.15 mg per kilogram IV or PO every 6 hours as needed (up to the adult dose).

You can give the sublingual form of Zofran to infants and young children--have the mom or dad sanitize their hands, then hold the tablet inside the child's cheek until it dissolves (about 20-30 seconds). It works great.

Alternative antiemetics that may be available in Haiti include Reglan (metoclopramide) and Compazine (prochlorperazine). I've seen a lot of Reglan used in Haiti in the past. Both of these have some potential complications, such as dystonic reactions, which you should be prepared to deal with (treatment is with Benadryl). Reglan can be given PO or IV. Compazine is best given either PO or IM, but can also be given IV. Compazine rectal suppositories may also be available but wouldn't work in the setting of severe diarrhea.

Reglan:

Adult dosing (>12-14 years of age, depending on patient size): 10 mg PO or IV every 6 hours as needed.

Pediatric dosing: 0.1-0.2 mg per kg PO or IV every 6 hours as needed (up to adult dose).

Compazine:

Adult dosing (>12-14 years of age, depending on patient size): 5-10 mg PO, IM, or IV every 6 hours as needed

Pediatric dosing: 0.1 mg per kg PO, IM or IV every 6 hours as needed (up to adult dose)

Zofran is safe in any age group, including infants. If possible, I would probably avoid giving Reglan or Compazine to infants under 24 months of age or so.

zinc replacement in cholera

2010-10-22T21:59:00.003-05:00

Zinc supplementation should decrease both the volume of diarrhea and the duration of diarrhea. From my searching, I can't find any absolute standardized doses, but I think these would be reasonable doses:

Children >2 years old: 30 mg of elemental zinc by mouth daily

Children >12 years old and adults: 100 mg of elemental zinc by mouth daily

pediatric and adult antibiotic treatment regimens for cholera--UPDATED

2010-10-22T10:34:00.007-05:00

PLEASE NOTE--I have updated these recommendations as of Thursday, November 4th. Please see the updated post HERE. Most of the information below was posted before antibiotic susceptibility data was available for the cholera strain in Haiti. I have left the post below for historical purposes ONLY. Thanks.

Someone requested that I write about antibiotic alternatives to Azithromycin for children. Please keep in mind that I've never seen a case of cholera (the vast majority of American physicians have never seen a case). I've studied tropical medicine and I've learned a lot about cholera, but the information I'm passing on is from the literature, not from my first-hand experience. I'm getting my information from several sources--the WHO and Uptodate.com being the main ones.

Also keep in mind that antibiotics should decrease the severity of diarrhea and the duration that someone is infectious, but they don't immediately cure cholera. People with cholera will still require large amounts of fluid (either ORS or IV fluids).

For children over the age of 12, you can use the adult dose of Doxycycline, 300 mg by mouth once. Some studies have shown that Ciprofloxacin is also effective, but there have been cholera strains isolated from areas in Africa and Asia that have shown significant resistance to Cipro, so I would only use Cipro if you don't have any Doxycycline, Azithromycin, or Erythromycin (see below). I've seen 2 different dosing schedules for Cipro: 1000 mg by mouth once, or 250 mg by mouth once a day for 3 days total. We don't have susceptibility testing from the cholera in Haiti yet, but even once we do have susceptibilities, remember that the susceptibility patterns could change quickly (as resistance develops to various antibiotics).

For children under 12, along with pregnant and nursing mothers, your options are Azithromycin (dosing in the post below) or Erythromycin. Erythromycin is dosed 12.5 milligrams per kilogram by mouth every 6 hours for 3 days (so 12 doses total). There are various formulations of erythromycin; all of them are dosed the same. The adult dose is 500 milligrams by mouth every 6 hours for 3 days.

I should mention that Ciprofloxacin isn't officially recommended for children or pregnant/nursing mothers, but in this situation you might need to consider using it if you don't have any other options. The risk of harm from a short course of Cipro in children, pregnant women, and nursing mothers is probably quite low. The pediatric dose is 20 milligrams per kilogram by mouth once. One study in pediatric patients showed that one dose of Cipro worked the same or better than 3 days of Erythromycin.

Resistance to Bactrim is high, so Bactrim should not be used.

If you can supplement with Zinc, that will probably help shorten the duration of the diarrhea.

Please also keep in mind the WHO guidelines for rehydration. The basic principles of rehydration are as follows:

1. Aggressively rehydrate (either with ORS or IV fluids--lactated ringers is the IV fluid of choice) people who are dehydrated until they show signs of improvement. NG tubes can be used for rehydration if IV fluids aren't available or an IV can't be placed.

2. Replace ongoing stool losses with equal volumes of fluid (again, either orally or IV).

Hope this helps. Please let me know if you come across any updated information that contradicts anything I've written.

p.s. For Lori and Licia specifically--If you have a suspected case amongst your workers, I'd strongly consider giving prophylactic antibiotics (same dosing regimens as the treatment doses) to all the kids in the Rescue Center. Official recommendations from the WHO state that prophylaxis is recommended if one family member out of five becomes infected. I don't know how to translate that exactly to the RC, but I would think that prophylaxis would be reasonable.

Possible cholera outbreak in Haiti--UPDATED--cholera now confirmed

2010-10-21T22:19:00.016-05:00

UPDATE: Cholera is now the laboratory-confirmed cause of this outbreak, according to the Wall Street Journal and Rene Preval, Haiti's president.

By now, many of you are probably aware that there is a possible cholera outbreak in central Haiti. None of the major organizations (such as the WHO, PAHO, or CDC) have confirmed that cholera is causing the outbreak, but others (like the president of the Haitian Medical Association) are confirming that this is cholera. I'm guessing we'll have confirmation from one of the big organizations in the next 24-48 hours. I still hope this is not cholera--but realistically, I think that it probably is.

I'm not currently in Haiti (though believe me, I wish I was--I hate being stuck here when I feel like I could be more useful there), but through reading articles, blogs, and tweets, it sounds like the level of alarm is quite high. Disseminating accurate information to people will be crucial in the next few days and weeks. Operating on the assumption that this outbreak is being caused by cholera, people need to know how to prevent cholera and when to seek medical treatment.

Even if this is not cholera, Haiti is still dealing with an outbreak of severe infectious diarrhea, and the initial treatment is the same, whether this is cholera or something else. As DokteCoffee (an infectious disease doctor currently serving in Haiti) says on Twitter, "immediate response to epidemic diarrhea is [the] same...what they need is clean water, salt and sugar in large amounts--and electrolyte solutions, is possible. nothing magical. many antibiotics for this type of diarrhea only need to be given once. again nothing magical."

If you are a health care worker in Haiti, here is a good overview of treatment for cholera (and shigella). The only modification I would make would be to consider using Azithromycin (if it is available) instead of Erythromycin, as it is much easier to dose (1 dose versus multiple doses). The Azithromycin dosing is 20 milligrams per kilogram, up to a maximum dose of 1 gram (1000 mg).

If you are in Haiti and need educational materials, please check here--this information is very useful and helpful. This blog has prevention information in Kreyol (though please note that this blog states that oral rehydration will not help much; I don't think this is true--please see below).

If this is cholera, please keep the following things in mind:

--There is probably going to be a lot of (unnecessary) fear among visitors to Haiti. The risk of contracting cholera is low as long as one is careful and has access to clean water and food and appropriate sanitation. And any visitor who contracts cholera will likely have much greater access to medical care than the average Haitian, so their chances of having a bad outcome from cholera should be low. This will not be the case for the typical Haitian citizen, however.

--Cholera is mainly spread by drinking contaminated water and (probably less commonly) eating contaminated food. It is very contagious in situations where people don't have access to clean water and adequate sanitation (so basically everywhere in Haiti). It can also spread directly person-to-person, though this is much less common. Not everyone who ingests cholera bacteria will become infected--you have to ingest enough bacteria to actually become infected. And, not everyone who becomes infected will show symptoms. However, if someone is going to become symptomatic, they will show symptoms within anywhere from a few hours to a few days after becoming infected.

--Prevention is key--it really does make sense in a time like this to be more careful than you'd otherwise be--wash your hands before you eat anything (as one blog states, "watch EVERYTHING you put in your mouth"), only drink water that is known to be clean, use hand sanitizer, wash your fruits and vegetables with bleach water, be cautious about eating out at restaurants or eating off the street, and so on.

--Cholera bacteria make you sick by attaching to the small intestine then producing cholera toxin, which makes the intestines secrete large amounts of fluid and electrolyes and also blocks the intestines from being able to absorb fluid and electrolytes. Essentially, people who are infected with cholera poop out massive quantities of fluid and electrolytes. If these aren't replaced rapidly you can die. The diarrhea from cholera shouldn't have any blood in it. If someone has bloody diarrhea, they probably have something else besides cholera.

--If you are in Haiti, please consider how you can help educate people about cholera. Many, many people are going to be at risk of becoming infected. Education doesn't need to be fancy or extensive---people need to know what cholera is, how it is spread, how to prevent it, how to treat it at home (and how to make oral rehydration solution [ORS]), and when to seek medical care. Pregnant women are especially at risk for dying from cholera (and for having their unborn babies die). Kids are at higher risk of dying too. I'm not trying to create fear by writing this--just the opposite actually. Spreading fear is not going to help this situation--but helpful information will.

--I think it's likely (and probably inevitable) that the outbreak will spread to Port au Prince. Someone who doesn't show symptoms for several days would have plenty of time to travel from a rural area to Port before becoming sick and then infecting others. Cholera could be quite devastating if it spreads to the tent cities and places like Cite Soley.

--If the outbreak spreads to Port, it's hard to say how bad it will be, though I suspect it will be bad.

--Treatment for cholera is lots and lots and lots of fluids, plus antibiotics. There are some on the internet saying that simple oral rehydration won't be enough, but that isn't necessarily true. For people who aren't vomiting and can drink, oral rehydration can be sufficient in many cases. You can make ORS by adding 1 teaspoon of salt and 8 teaspoons of sugar to a liter of water. People can do this in their homes/tents/etc as long as they use boiled or treated water. If people can't drink ORS, they will need IV fluids (preferably Lactated Ringers). IV fluids with dextrose shouldn't be used, at least not initially. People with cholera can require massive amounts of IV fluids.

--Antibiotics for cholera are easy (just 1 dose), which is nice. If people are vomiting, a dose of Zofran (or another antiemetic) before the antibiotic should help them keep it down, or you can wait until their vomiting has stopped. Antibiotics don't exactly cure the infection, but they do reduce the duration of diarrhea and they reduce the duration of time someone is infectious. Non-pregnant adults should get one dose of Doxycycline, 300 mg by mouth. Pregnant women, women who are breastfeeding, and children should get one dose of Azithromycin. The adult dose of Azithromycin is 1 gram by mouth. The pediatric dose is 20 milligrams per kilogram by mouth, up to a max of 1 gram (1000 mg).

--I think one of the more difficult things is going to be sorting out who has regular old diarrhea (either from a bacterial or viral cause) and who has cholera because diarrhea is so common. In general, people with cholera are going to get really sick, really fast. If someone has had diarrhea for a day and they're pooped a few times and are up walking around and look fine, they probably don't have cholera. If someone just got diarrhea an hour ago and they've pooped 12 times since then and they look terrible, they probably have cholera. In between those 2 extremes, it's going to be more difficult to know. But in the setting of a probable outbreak, it's never going to be wrong to give the antibiotics and start giving ORS.

I hope this information is helpful. If anyone has any comments or suggestions for how to improve this information, please let me know.

Haiti storm

2010-09-24T20:48:00.007-05:00

We had a huge storm here this afternoon. We drove to Double Harvest Hospital this morning to pick up some post-op patients. On the drive back I noted the bright blue, nearly cloudless sky. We unloaded the patients and got them settled. I worked on making charts for the 7 new patients we'd received. A couple hours passed. Then Chris came in and said, "Hey, it's going to rain hard." I looked at the sky and it was dark. Then the wind started blowing. There were only a few raindrops at first. But I (we) could tell right away this was going to be bad. We ran around quickly and closed all the windows and doors in the tents that are housing our patients. Within seconds the sky opened up and sheets of rain began pouring down.

Then the wind really picked up. We have about 12 people, mostly former patients who are currently living at the hospital, whose beds are under a large concrete overhang outside. When the wind started the people whose beds were closest to the edge of the overhang were quickly drenched. With the other patients (mostly) protected by the huge, sturdy tents we're borrowing from MERLIN, we focused our attention on protecting our other patients from the storm. This was quite a task. Someone ran in back and grabbed a few extra tarps. We already had some tarps set up, but the one hanging over us filled with a huge amount of water more quickly than I could have ever imagined. With 100s of pounds of water hanging precariously over our heads (and being held up by who knows what---the tarps were "secured" by something on the roof sitting on them--I'm still not sure what), some started to push at it with crutches (this is how we roll here when it rains...degage). They weren't able to generate enough force with the crutches to force the water out. With the huge bowl of water growing and me worrying that we'd all be in trouble soon when the whole tarp system collapsed, we decided to cut a big hole in the bottom. What happened next is the definition of a deluge. But at least we no longer had the 100s of pounds of water hanging over our heads.

Then we focused on holding up one large tarp to shield the patients. This was easier said than done. At the height of the storm, it took about 4 of us holding it and leaning against it with our full weight to keep the rain and wind from coming in. Even then it almost blew us over several times. There were these intermittent, frequent, intense wind gusts that would go on for about 30 seconds at a time. This went on for maybe an hour--I don't really remember. Every minute or so the tarp above us would shift as the rain collected and huge boluses of water would pour through the now severed tarp onto all of us below. At one point fairly early on I realized this was different from other storms. One of our new volunteers was standing next to me, holding a large piece of plywood to block more of the rain. I kept telling her this was an anomaly, and that I'd never seen anything like it here (I was in Haiti for a tropical storm once, and this was far worse. I've never been in a hurricane in Haiti).

As I held up the tarp and threw the full weight of my body against it, I continually thought of those living in the tent cities. I knew there was no way that flimsy tents and tarps could withstand this kind of wind and rain. Pictures taken after the storm have shown this to be true. How unfair, and unjust--as many have said, it's been over 8 months since the earthquake. Hurricane season is not a big mystery--it happens at the same time every year. And while this wasn't a hurricane, it might as well have been (though a hurricane or severe tropical storm would definitely be worse, as it would go on for much longer). There has been time to prepare for something like this. People shouldn't be suffering because of the weather.

As the storm subsided, I stood there freezing cold and soaked. But then I went inside and found a towel and a change of clothes. We helped our patients dry off and provided dry sheets and clothing as needed. Within a few hours things were basically back to normal at the hospital. Tomorrow there will be some more cleaning up to do as several of our smaller tents flooded. But all in all, it wasn't all that difficult for us once the storm was over. But life outside our walls it is a different story. Trees and power lines are down. Streets are flooded. Tent cities are a mess of ripped tarps and collapsed tents. As the rain continues to intermittently sprinkle down tonight, many are again homeless, now without even a piece of plastic to protect them from the elements. I don't have a lot of answers--but what I do know is that this is an injustice that didn't need to happen.

Pa bliye Ayiti~~Don't forget Haiti~~pray/hope/give/remember

**Update: apparently this type of storm is called a "microburst". You can read more about it here. The organization mentioned (JP HRO) is doing amazing work in Haiti. They've helped us out on numerous occasions. The people working there are compassionate and incredibly hard working. Please pray for them as they rebuild, and for all the people they're serving in their camp.

healing

2010-09-04T23:33:00.008-05:00

Rosemond and his grandma came to Heartline Hospital on January 25st. He's told me many times that he remembers that first day well. His injuries were severe, and he was a very sick little kid. With lots of antibiotics, dressing changes, skin grafting at MERLIN, and lots of TLC from his grandma (who rarely left his side for weeks) and hospital staff, he slowly improved. One of his injuries, however, didn't improve with time--it got worse.

We knew as early as February that Rosemond would need specialized surgery to correct his hand/wrist problems. These problems resulted from a crush injury to his forearm, which lead to severe nerve damage. As you can see in the picture below, his hand and wrist were very deformed. Any movement of his fingers, hand, or wrist was extremely painful. His fingers and hand were essentially "locked" in one position. You can read more of Rosemond's earthquake story here.

(mid-February, 2010)

A plastic/hand surgeon from MERLIN assisted us with specialized splinting of Rosemond's hand. An organization in the U.S. generously offered to help us secure a medical visa, and an orthopedic surgeon offered to donate his services. For many (social and psychological--not medical) reasons, we didn't think that traveling to the U.S. for surgery was Rosemond's best option, but we continued to pursue it because we lacked any other options.

In April, we heard (last minute) about a visiting team of surgeons operating out of L'hopital de la Communite (in Port au Prince). We made some phone calls and got permission to bring Rosemond to see their hand surgeon, Dr. Mike, the next day. Dr. Mike and his team performed a tendon transfer surgery in late April. Rosemond's arm was in a specialized cast (applied and re-applied many times by surgeons at Medishare and other facilities, along with Dr. Cliff).

We all sort of held our breath when his last cast came off in early July. It took a week or two, but slowly, we could see that things were much better. Sendy (a young Haitian woman who's been working with us since March as a physical therapy assistant) worked with Rosemond day after day throughout July and August. When I left Haiti in mid-July, Rosemond was showing a lot of improvement, but he was still very hesitant to use his right hand. We had to remind him (and sometimes force him) to eat with his right hand. We were worried that he would continue to favor his left hand, and end up with a functional, but not very useful, right hand.

Thankfully, he proved us wrong. When I arrived in Haiti in late August, one of the first things I noticed was how naturally Rosemond was using both of his hands. And to my surprise, he was also writing perfectly with his right hand. He'd improved far faster than I expected, and it made all of us really happy.

Dr. Mike gave him a second chance at having as normal of a life as possible in Haiti. Rosemond will still face enormous challenges as he adjusts to his new life after suffering through incredible loss. He will now grow up in a Haiti forever changed by 45 seconds of the earth shaking. Nearly everything that he knew in his previous life is gone. But he will face all of these challenges with a healed, whole body, and an extended family who loves him.

We are so grateful for everyone who's taken care of Rosemond since January, and I hope you're encouraged by seeing the end result of all of your hard work.
(On a side note, Rosemond has gained about 25 pounds since January, and I'm guessing he's grown about 6 inches taller!)

(late August 2010)

(writing a letter to Dr. Mike, late August 2010)

updated medical volunteer needs

2010-09-02T17:21:00.005-05:00

Thanks to everyone who has volunteered to work with us in September and October. We are still in need of 1-2 nurses and paramedic to volunteer at Heartline Hospital from around 9/19-9/27, and a physical therapist from around 9/20-10/5. Please contact me at halv0105 AT umn DOT edu if you are interested. Thank you!

Amanda and Patrick update

2010-08-31T22:57:00.007-05:00

Amanda has had 2 long, but very productive days, at Mayo. I knew, from some limited past experience (I interviewed at Mayo for both medical school and residency and I have a family member who receives care at Mayo) that Mayo is a very warm, professional, and well-organized place. I knew Amanda would have a good experience. The care she's gotten so far has exceeded all of our expectations.

People have been helpful, welcoming, and friendly at every step--the guys who meet you at the curb with a wheelchair, the workers in the international office, the receptionists on every floor, the doctors and nurses, all of the various techs (lab, radiology, etc), the volunteers, and everyone else. Several organizations in Rochester (Minnesota) have provided housing and food for us. We are blessed.

Over the past 2 days, Amanda has had consultations with multiple doctors, several different x-rays, blood tests, an MRI, and a couple other big tests. She has one last big test tomorrow. Surgery is scheduled for September. The days are tiring for her, but aside from the fact that she's freezing (hospitals are so cold!), she is really hanging in there. I explained the usefulness of tunnels and skyways (especially in the winter!)--Mayo has many of each--she thought they were a great idea.

the awesome MRI nurses gave her many warm blankets...she was in heaven

Theresa asked me the other day if Amanda knows that there are no earthquakes in Minnesota. I realized that I hadn't told her this yet, so I let her know. She was relieved, and told me she'd been worried about being in any building taller than one story. Several of the Mayo buildings are very tall--up to 20 stories. We've been spending a lot of time on the 14th and 15th floors. Amanda told me that she felt the building move once. I told her it might have been the wind, and reassured her again that the buildings are safe. She isn't really afraid--she will stand at the floor-to-ceiling windows and look out over the surrounding areas, and she likes the view. She keeps asking me how these types of buildings are constructed. I've told her they use a lot of "gwo machin" but beyond that, I can't really describe it. Coming from Haiti, she understandably can't imagine how this type of construction is even possible.

first McDonalds!

The first night we were in Rochester, Theresa, Amanda, and I had a lot of fun looking at pictures and watching videos from the past several months. Amanda especially loved watching the video of one of the nightly church services, saying "I miss that." I reminded her that when that particular video was taken, she was in severe pain from all of her injuries. I asked if the church services helped her forget her pain, and she said yes, everyone could forget during those times. More evidence that healing and pain relief don't come solely from medications.

watching videos

Please continue to pray for Amanda during the coming weeks. Thanks to everyone who's helped her get to this point!

Patrick update: I talked with Patrick's host mom today. Patrick is doing great. His English is improving quickly and he started high school today. He's a really smart kid. He's been working on his host family's farm and making a little money. He recently went shopping and spent all of the money he'd earned so far (about $30) on gifts to send to 2 of his friends (other patients at Heartline Hospital) in Haiti. He also sent several fancy Lego sets he'd been given as gifts (by people at the hospital he's being treated at) to another one of the patients in Haiti. He's a neat kid. He will stay in the U.S. until next summer.

nou la (we are here)

2010-08-29T12:24:00.005-05:00

wheelchair ride to the plane in Port au Prince

Amanda and I made it to Minnesota late last night after 2 long days of trying to get here. We were supposed to leave on Friday morning, but after sitting in the Port au Prince airport for about 7 hours, our flight to Miami was cancelled. Amanda did great that whole time, resting intermittenty and reading, but I could tell the whole day was really tiring for her.

We went back to the Livesay house to spend the night. Jeronne, the amazing woman who lives and works with the Livesays, has gotten to know Amanda over the past few months, and they've become good friends. She immediately began taking care of Amanda--took off her shoes, helped her lay down for a rest, made sure she had a fan, prepared dinner, washed her clothes, gave her one of her own shirts to wear the next day, helped her get ready for bed, and set up a movie on a portable DVD player. She ended up sleeping in the bunkbed above her, at Amanda's request. It was so, so sweet to watch. Jeronne is a caretaker in every sense of the word.

Seeing air travel through the eyes of someone who is flying for the first time is interesting. I never really thought about it before, but the safety instruction video makes it seem like needing to use the oxygen masks, having to put on a lifejacket, and needing to evacuate the plane in a boat are all normal occurrences. As the video played on Amanda glanced at me and asked "Why do we need to do that?" I told her about emergencies and explained that I've been on many flights, and I've never had to do any of it. She seemed fine with that explanation and never looked nervous on any of the flights. She loved flying through the clouds and, like me, thinks airplanes are entirely too cold. We "borrowed" 2 blankets from first class on the second flight. Whoever decided to do away with blankets in coach is obviously more warm-blooded than I (and many others) are.

I had forgotten many little details of Amanda's story, so I had her tell me, day by day, the whole story again. She's been in seven hospitals since the earthquake. Mayo will be her 8th. She has suffered a lot--more than I even realized. She described the misery and death that surrounded her at every hospital, on every street corner, in each moment. Physical healing is really only the beginning for so many who've suffered since January 12th.

We had wheelchairs lined up at all of the airports and it worked out great. We easily passed through immigration and customs in Miami without any problems. Randy Mortensen from World Wide Village happened to be on the same flights and traveled with us the whole way. He was a great help.

Amanda will be staying with Theresa and her husband, as well as with Theresa's mom and dad, while she's in Minnesota. They picked her up at the airport last night. I talked to Theresa this morning and she's doing well. Theresa's parents live on a farm with many roosters. Amanda's feeling right at home :)

We head down to Mayo soon to begin the last leg of Amanda's journey of physical healing. Thank you to everyone who's worked so hard on her behalf!

There is Hope--part 3--The Story of Heartline Hospital

2010-07-31T05:17:00.001-05:00

You can read part 1 here and part 2 here. (My apologies that it's taking months and months to tell the story...it's a long story and it's still in progress!)

Within the first 6 hours of the clinic/ER/OR being open, it became very evident that we'd need an inpatient ward for patients too sick or injured to return "home". In retrospect, we should have anticipated this need in the days before we opened. But at the same time, I look back on those first days and I can remember how intense they were, and how many unknowns we faced. We could barely anticipate what the next hours would bring, let along the next days or weeks. I remember that on one of our very first days, someone e-mailed me and asked about volunteering in March. I remember thinking to myself, "March? Are you serious? It's difficult to even anticipate what volunteers I'll need next week..." It wasn't that I didn't appreciate the offer of help (I did), it's just that, at that point, it was impossible to plan that far ahead. In light of that reality, it's not surprising that we didn't think of the need for an inpatient ward before we started.

makeshift inpatient ward, outside ER/OR, night #1, 1-18-10

It didn't matter---everyone stepped up to make it happen. On that first night, we housed about 10 patients in our ER/OR area and in the outside courtyard. We quickly realized that this wasn't a viable long-term plan. On the second night we started moving some patients over to Heartline's former "boys home" (where about 10 boys waiting to be adopted lived prior to the earthquake), just one street over from the ER/OR. We started out with very little---a few army cots, some mattresses on the ground, one tent in the driveway, a few tarps strung up with rope, as many sheets and towels as we could pull together, a makeshift charting system, MREs, IVs hung by pieces of gauze used as rope, and a few medical providers volunteering to work the night shift, including one Haitian nurse, Wini, who showed up on day one wanting to help us out. After a few days we were able to officially hire her, and she's still working with us.

early inpatient ward, 1-22-10

Over time, the inpatient ward evolved. Little by little, we acquired more cots--a few from here, one from there, two from someone who happened to stop by and drop them off. It went on like that for awhile, until we were able to bring in a bigger load of cots on one of the charter flights after a week or two. We also acquired a growing supply of sheets, towels, and other necessary supplies. We organized a better meal schedule, including nutritious high-protein meals three times a day. Looking back now (at the end of July), it's still hard to believe how little we had at first, but we made it work.

1st inpatient census board, ~1-20-10

The tarps provided sufficient cover until the end of February, when the rains started. A visiting group put up a more permanent half-dome tent structure in early March. Other organizations continued to donate supplies to us. Eventually, sometime in early February, we had acquired enough cots so that everyone could sleep off of the ground. We would occasionally have a patient sleep inside the house, but this was rare, as no one wanted to sleep inside a house made of concrete blocks. And when you saw their injuries (most inflicted by falling concrete blocks) you could understand why.

makeshift traction, 1-21-10

Prioritizing our needs during those first couple weeks was incredibly difficult. Each charter flight had a strict weight limit. In the beginning we needed everything, and we needed it all right now---a huge variety of medical supplies (everything from penrose drains to crutches to casting material to urinary catheters to wound dressings to a cast cutter), medications, medical personnel, food, cots, sheets, office supplies, and everything else you can imagine you'd need to run an ER, OR, and hospital. But we couldn't have everything right now, so we made do with whatever we could get.

I just looked back at one of my "supply wish lists" from the first weeks, and it brought back some very specific memories. I remember people handing me lists--black Sharpie marker scribbled on a ripped off piece of cardboard box, blue pen on a half sheet of notebook paper, copies of our makeshift charts covered in notes. It wasn't uncommon for me to update the supply list several times a day. The U.S.-side people had to deal with my very frequent e-mails, nearly all of them marked "urgent!", and they did a great job getting us what we needed, over and over again. We were flying in about two charter flights per week during the first few weeks, so the state-side volunteer staff had a HUGE job. They worked just as hard as any of us who were on the ground in Haiti.

We would get e-mails from random people offering supplies, and we took advantage of every generous offer of something we needed. Sometime this involved trading. I remember one day John Ackerman walked in with morphine. We needed morphine in a bad way. He handed it to me, asking, "So what are you going to give them?" "Who's them?", I asked. "The Germans," John replied. I think I started laughing at the absurdity of the whole situation. I didn't ask him to elaborate on what he meant by "the Germans" and I didn't care---I was so happy to finally have some more morphine. I gave John a couple boxes of Versed (we had lots of this) and we called it a deal. Needless to say, there is no DEA in Haiti.

Another connection brought someone from the U.N. to our hospital. She handed me a list of medications that were stocked at a warehouse...somewhere in Port au Prince. If I'm remember correctly, it wasn't a U.N. warehouse, but she had access to it. I quickly read through the list and marked off the medications that we needed. I was a little skeptical that we would actually get what I "ordered", but I was willing to try anything at that point. The following day, she showed up with boxes of medications--including Tetanus vaccine (the first we'd had since opening). It felt like Christmas! What a relief.

On January 23rd, Tara wrote the following:

A US Military person told me (Tara) that he was very upset with the lack of urgency for getting them on the ground and set up. He said they were made to sleep at the Embassy because no one would pull the trigger and give them clearance to go set up. They talked about danger and seemed not to know who had the authority to give them their marching orders. He said it took 9 days from his deployment to get to his post. He said there are politics in play and that it had been frustrating for him and his team. Meanwhile, independent, unarmed, non-military missionaries and aid-workers are running around the country without much trouble at all.

Having shared that, it has been amazing to see the ways little organizations have worked around the red-tape and the ridiculous politics and have found their own supplies and have traded out and rallied together for the greater good. Please continue to pray for order, cooperation, and successful teamwork -- it can only benefit the hurting if we all play well together.

This was our experience over and over again. We quickly realized that the best way to get things done was to network and work together with other organizations (usually small NGOs, though not always). When we had extra supplies or medications, we gave them away to people we knew needed them. When others had extra supplies, they showed up at our hospital to give them to us. It was beautiful. We also had the big advantage of not being limited by restrictive rules governing our movement. We had vehicles, we had diesel (brought in from the D.R.), and we had the freedom to travel around the city wherever we wanted, whenever we wanted. This wasn't the case for many other organizations, but it was critical for getting things done.

The stories our patients told us were unbelievable and heartbreaking. Buried alive for days. Laying outside for over a week with an open fracture and no medical care. Laying among dead bodies waiting to be rescued. There was fear and trauma on people's faces and in their eyes. One volunteer who worked with us back in January came back to volunteer again in May. He commented to me, "No one smiled or laughed back in January, but there is so much laughter now." He is mostly right--there were a few light moments in those first weeks that he didn't see, but not many. The injuries we treated were horrendous. We witnessed, over and over again, the extreme injustice that flows from the lack of medical care and the lack of a health care infrastructure.

6 month old baby with deep arm laceration...no care for 7 days...can you imagine?

Over the first two days of being open, we took in around 20 people who needed inpatient care. Of those patients, we had 11 who needed urgent surgical care that we couldn't provide. Many have already heard the story of how we connected with the USNS Navy Comfort ship on January 20th (the day after they anchored in the port, and the first day they started taking patients on board). Tara blogged about it here. I haven't written much about that day. At the risk of sounding overdramatic (which is not my intent), let me say this--it was, hands down, one of the most surreal, crazy, and ultimately, amazing days of my life. I want to tell the story in my own words...that is coming up in part 4.

tara watching helicoptors from the USNS Comfort take off with our patients, 1-20-10

update on Amanda

2010-07-24T12:57:00.000-05:00

I have been waiting almost 4 months to write these words: Amanda has been accepted for comprehensive charity care at a hospital in the U.S.!!! Words cannot adequately express how grateful I am, but I want to say a huge THANK YOU to her accepting hospital, Dr. B at the accepting hospital, the charity care committee at the accepting hospital, Rachel with Medical Advocacy Team, Marilyn (executive director of an organization that helped with letters), Monique the lawyer from D.C., all of the EMTs, medics, nurses, physical therapists, physician assistants, and physicians who've cared for Amanda at Heartline since early March, all of the medical personnel in the Dominican Republic and at MERLIN who cared for Amanda prior to early March, and everyone who has prayed, e-mailed with offers of help, and spoken encouraging words to all of us throughout this process.

walking unassisted, June 2010

You can read more about Amanda's story here and here (see the June 23rd post "Fallen Houses Broken Bodies").

the rubble of the house Amanda was in (just beyond the standing wall) on January 12th, picture taken June 30th

When I received the official news of Amanda's acceptance earlier this week, I was sitting on my couch. After reading the short acceptance e-mail several times, and convincing myself that it really was saying what I thought it was saying, I laid my head back, closed my eyes, and exhaled....for a long time. It felt like I was releasing almost 4 months of stress, tension, uncertainty, and fear. Fear that we had lost 4 months of valuable time. Fear that Amanda would live the rest of her life with a non-functioning left arm.

I very clearly remember picking up Amanda at MERLIN Field Hospital back in early March. I'd actually heard about her several days prior, and she was supposed to transfer to Heartline Field Hospital the day prior to when she actually did. The MERLIN staff described a young woman who'd been crushed all along her left side when the house she was in collapsed on her. She had a severe femur fracture with an external fixator in place, a humerus fracture that had become infected, a foot wound that had been skin grafted, and a brachial plexus injury that left her with a severely painful and completely paralyzed arm.

I was at MERLIN the day before Amanda came to us, and was ready to pick her up along with another patient. However, the staff at MERLIN told me that Amanda was hesitant to come to Heartline--she'd heard through the grapevine (a LOT of our patients spent time at MERLIN, and they talk!) that "le lapli tonbe, tap yo koule e tout moun vin mouye"--when it rains, the tarps leak and everyone gets wet. Now, that was not completely true, but it is true that right around that time we were having some serious issues with our intricate tarp system (and the rains, which held off until mid-February, were coming frequently). We also happened to be fixing the tarp system that day--and the hospital grounds were a mess. So it wasn't the best day to bring her back.

constructing the new tarp/tent, March 2010 (photo by Morgan McHoul)

new tarp/tent from outside the gate, March 2010

We went the next day instead. I walked into one of MERLIN's makeshift hospital tents, located on what used to be several tennis courts in the Delmas neighborhood of Port au Prince. I walked over to Amanda's bed, and she gave me a small smile. She sat up straight and looked me in the eye as I introduced myself and explained that the MERLIN doctors wanted her to come to Heartline, because we could provide some care that they weren't able to. She needed around-the-clock IV antibiotics for at least 2 weeks, and while MERLIN could do an amazing variety of operative interventions that we (obviously) couldn't do, they were less able to provide 24/7 IV medications. That's part of the reason our 2 hospitals worked so well together--our strengths and weaknesses complemented each other perfectly, and MERLIN continued to assist with Amanda's care after she was transferred to us.

Amanda listened to everything I had to say, including the fact that we had just put up a giant, new, half-dome tent structure. I promised her that she wouldn't get wet when it rained, a promise that has (mostly) been true. I then asked her if she was okay with coming to our hospital. She paused for a brief second, nodded, and said "wi". She asked a couple other brief questions, and then we were on our way.

Everything about the trip from MERLIN to Heartline--moving her from her bed to the back of the pickup truck, driving the 3 miles between the hospitals, moving her from the pickup to her new hospital bed--was painful for her. Every bump in the road (so basically the entire drive) caused her femur external fixator to move, and even small movements were nearly unbearable. We drove as slowly and carefully as we could...but you know how it is.

typical road here...one of the more decent ones

That first month at Heartline was one of excruciating pain for her. Any movement caused severe pain in her unhealed femur. And the lack of movement (i.e. the brachial plexus injury) caused severe, constant, incapacitating, burning nerve pain in her entire left arm. Everything about her day-to-day life was difficult. She cried frequently. We provided strong narcotic pain meds (both oral and IV), but it is well-known that even narcotics can't do much to relieve "nerve" pain. And while her other injuries slowly healed, we felt helpless when it came to her brachial plexus injury. Some suggested amputation, but others pointed out that even with amputation, the nerve pain would likely continue as phantom limb pain. Can you even imagine? I know I can't.

In April we put out the word that we were looking for a neurosurgeon to help Amanda. We knew she needed operative interventions for her arm that were far more complicated than what could be done in Haiti. We received many helpful suggestions and offers--thank you so much to everyone who contacted us! We started working on her case at the U.S. hospital at which she was ultimately accepted, a process that we originally thought would take several weeks, but ended up taking several months. In mid April, Barbie made contact with an Air Force anesthesiologist, who placed an intraneural catheter into her brachial plexus, allowing us to infuse a long-acting anesthetic. This gave her about 3 weeks of relief from the arm/nerve pain. Interestingly (and thankfully), towards the end of April, her nerve pain started to improve with a new combination of medications even after the catheter was removed.

In late April, her femur external fixator was removed, but she unfortunately continued to have a lot of pain and difficulty with any movement. In early May, a visiting orthopedic physician assistant made a beautiful, intricate, specialized "hinge cast" for her leg, allowing her to much more easily transfer from her wheelchair to her bed (thanks Cliff!). I've been told that making a good hinge cast is becoming a lost art these days, and that very few people can actually do it right. But Cliff is a cast artist!

with Cliff, mid-May 2010

On one of my last days in Haiti earlier this month, Amanda asked me for a new sling. I wasn't sure that we had any, but I did find one. I gave it to her, but instead of putting it on, she carefully hid it amongst her belongings, and told me, "M'ap sere li jistan w tounen pou mennem'm ale zetazini"--(I'm paraphrasing...hoping the Kreyol is correct...it was something along those lines)--basically, I'm putting it away, or saving it, until you come back to bring me to the United States.

Theresa, April 2010

Amanda will be staying with Theresa, a nurse who spent a couple weeks with us in late January and early February, and another week in April, and her husband. I can't think of a better host family for her--thanks so much Theresa and Matt!

July, 2010

On July 13th, I passed through immigration at the Miami airport like I've done dozens of times before. My one prevailing thought as I passed through there was "I really, really hope that the next time I do this, I'm with Amanda." And that is very likely going to happen. Soon. I can't wait.

Amanda has a visa appointment at the U.S. Embassy in Port au Prince next week. Please pray that she receives the specific type of visa that we're requesting so that she can travel as soon as possible.

walking without crutches for the first time, July 2010, exactly 6 months after the quake

entertaining the hospital, April 2010

(videos, pictures, and information posted with Amanda's permission)

long-overdue update

2010-07-16T10:13:00.003-05:00

Many apologies for the long blogging hiatus. I admit that when I'm in Haiti, blogging ends up at the end of the (long) list of things that need to get done every day---which means it rarely happens. Haiti sucks up time like no other place I've ever been. One typically starts the day with a long list, and you're always lucky to finish everything on it before the day is over (this rarely happens...).

Since leaving at the end of April, I've been able to travel back to Haiti twice. I was here for 2 weeks in May, and I came back on June 28th for another 2 week trip (leaving on July 13th). Going back and forth has been difficult, but it is a privilege that is so worth it.

During the May trip, I spent a ton of time working on medical visa paperwork for 2 patients. One of the patients left for the U.S. last week!! It is amazing to me, though I guess not unexpected, how much work is required to get a child out of Haiti for medical care. It is so worth it, though. Knowing that he will be in the U.S. for the next year, being watched very closely for any signs of ongoing infection or other complications, is a huge relief. His host mom came to Haiti to escort him out, along with a really nice representative from American Airlines. I was able to go all the way to the gate and wait until they boarded the plane. Very cool.

In May, we also coordinated many follow up appointments, organized supplies at the hospital, visited previous hospital patients, and coordinated surgical care for a couple patients with ongoing complications from injuries they sustained in the quake. Yes---even 5+ months post-injury, people here were/are still dealing with complications. Certainly some complications are expected, even in the developed world--but the complications I've seen are directly related to the fact that people did not receive the care they needed during first hours, days, and weeks after the quake.

That May trip flew by...2 weeks is really not enough time in Haiti (is any amount enough time?).

We've taken care of several amputees since the quake. Two are still with us--Emmanuel and Antoinett. Both have incredible, amazing, unbelievable stories. Both are still healing physically, emotionally, and spiritually.

In late June, I visited Emmanuel's parent's home out in the mountains past Miragoane along with Troy, Paige, Jessica, members of Emmanuel's family, and a couple of the other Heartline patients. You can read more about the adventures we had that day here. Emmanuel's been living with family in Port au Prince since he was pretty young (around 6-7 years old, I think). His relatives in Port were able to provide him with opportunities he wouldn't have had in the village, such as advanced schooling. This was the first time his parents had seen him since the quake. Emmanuel told me that family members had called them the day after the quake to tell them Emmanuel had died. It wasn't until a few days later that they heard he was actually alive.

One thing that struck me about that day we visited his home (along with everything else) was seeing pictures of Emmanuel on the walls of his parent's tiny, damaged house. They were all taken on the same day a few years ago, when Emmanuel was helping construct a road in their village. He looked strong, confident, happy, carefree...like a "normal" teenager. Now he's a 21 year old amputee, in a devastated country with an uncertain future. The home he's known for 10+ years (in Port au Prince), the home he shared with his extended family, is a pile of rubble that looks like a bomb was dropped on it. His school is completely gone. Many of his close family members are dead. One of them died right next to him where he was buried for 2 days before being rescued.

I stared at the many pictures on the cracked wall as Emmanuel's dad proudly pointed out various features of the pics to me: "Look at him working...Look at what he was doing." Later on, Emmanuel himself showed me the pics again. I wondered what was going through his head as he studied each picture...anger? Frustration? Hope? Longing? The realization of how quickly life can completely change? I tried to imagine how I would feel in the same situation, and I have no idea.

And for Emmanuel's dad--what must be going through his head as well? Does he still believe that his son will be able to complete school? Get married? Find a job? The uncertainties of life here can make one question everything.

One thing I do know is that Emmanuel is loved by a lot of people. When he walked into his family's home in the village, he was immediately surrounded by friends and family, conversation and laughter. When he walked back into Heartline a few days later (after his visit home to Miragoane), he was greeted like long-lost family. When he's having a hard day, he has multiple people with whom he can talk. He doesn't have to put on a "happy" face at the hospital---if he's sad or down, he can freely express those feelings. People give him the space he needs, but they are also there for him whenever he needs them. I am continually amazed by this young man's bravery, compassion, and spirit.

resilience

2010-04-25T07:04:00.004-05:00

standing on the rubble of a patient's house

2010-04-24T00:27:00.007-05:00

When I visit the piles of concrete and reibar and dust and debris that used to be the houses of our patients, I am continually struck by the same thought---how did anyone who was inside these buildings survive? And yet we have a hospital full of people who DID survive.

Each patient's story is unique, tragic, hopeful, and sad. Tara is going to be posting many of our patient's stories over the next couple weeks. She started with Marie Rose's story. As we move towards completing the acute medical relief phase of this work, Heartline will begin addressing the long-term housing needs of those who are now homeless. If you are moved by their stories and have the means to help, please consider giving to Heartline's housing fund. These people need a new place they can call home---a place to start healing and rebuilding their lives. Thank you.

tuesday

2010-04-20T22:09:00.007-05:00

There is a huge gas & diesel shortage here currently. Some of our vehicles take gas, though most take diesel. All of our vehicles are running close to empty, and we're buying fuel a gallon or two at a time. Prices are through the roof---one of the guys here bought 4 gallons of gas for US$50 today. He purchased this in a can from someone on the street. The lines at the gas stations (the ones that actually have a little bit of fuel) are really long. I'm assuming prices at the stations are just as bad. We have 5 gallons of diesel left in a container---tomorrow morning 3 gallons is going in one truck and 2 in another, so that we can transport four patients to two different hospitals for various surgeries. Yes, we still have patients who need surgery, now 3+ months out from the earthquake. No, I didn't anticipate it would be this way either! If I had, I would have taken a very long leave of absence starting back in January. If I had done that, I wouldn't find myself again facing an upcoming departure that is going to happen far too soon. Live and learn, right? If I'm ever involved in another disaster response, I'll know what to do (and what not to do...)

Three of the patients being transported tomorrow are getting various hand surgeries at L'Hopital de la Communite by a visiting hand surgeon from Tennessee. The opportunity to see this hand surgeon arose very unexpectedly at the last minute, and we are grateful. The other patient will be having a fibular osteotomy and tibia bone graft---her tib/fib fracture has not healed despite weeks and weeks in a combination of an ex-fix and various casts. This surgery will be done at Adventist Hospital in Carrefour by another visiting surgical team. These 2 hospitals are on opposite ends of the city. Hopefully those 5 gallons of diesel will be sufficient for Wednesday's transports. We keep hearing that tankers with diesel are arriving soon. I'm not sure what "soon" means. On Thursday, Friday, Saturday, and Sunday we have numerous other transports that need to happen--and the 5 gallons of diesel probably isn't going to last beyond tomorrow. I suspect things will work out---they always seem too, somehow. John posted more about the fuel shortage here.

One saving grace is that so far, city power has been consistent (knock on wood...) meaning we don't need to run the generators (which use diesel) very much. That helps a lot.

Yesterday we did our last official "truck run" (or at least we think it will be the last). The vast majority of wounds we were taking care of in the field are now healed. This whole operation started with the first "truck run" back on January 18th. That seems like a very long time ago. On that first day, our large white cantor truck drove into the slum of Simon Pele and picked up our first load of severely injured patients. The truck has taken hundreds and hundreds of trips since then, into and out of Pele, Cite Soleil, Wharf Jeremie, and numerous tent cities. I believe the truck had less than 100 miles on it prior to the quake (it was brand new). Now it has driven thousands and thousands of miles, transporting patient to and from the hospital to their homes, tents, shacks, MERLIN field hospital ("Delmas 33 tennis courts"), Medishare field hospital ("Miami"), Double Harvest hospital, the USNS Navy Comfort ship (via Terminal Varreux), and multiple other places. The truck is well known as a small oasis of healing in many slums and neighborhoods around Port au Prince. It was definitely bittersweet to finish this piece of the work we've been doing. You can see some of Beth's pictures from yesterday here.

Recently I've had a couple people ask me for specific pictures from the first couple weeks after the quake. As a result I've been looking back through hundreds of pics from those first days of the clinic/hospital. Wow. This small field hospital has quite a story behind it and within it. So many talented and generous volunteers, so many courageous patients, so many obstacles, so many tragic stories, and so many stories of hope. Someday I hope I can write more about the things I've seen, heard, learned, and experienced over the past 3 months.

creative PT

2010-04-19T07:22:00.003-05:00

We've had a few various PTs from Medishare and Quisqueya Earthquake Relief over the past week. All of them have been amazing---calm, compassionate, fun, and very creative, especially when working with the kids.

one more ex fix off

2010-04-16T00:39:00.006-05:00

Our team found Liliane lying in her small house in Cite Soleil. She was outside during the earthquake, and was severely injured when her neighbor's house fell on her. A couple weeks after the earthquake, a hospital in Port au Prince placed an external fixator on her upper left leg to stabilize her femur fracture. She also suffered a broken right arm. She was discharged from the hospital shortly after the ex fix was placed.

She was discharged back to a slum, where she did not walk or move much for the next several weeks. Hygiene is difficult here on a good day, so it's not surprising that her ex fix pins became infected.

After finding her, we brought her to Heartline, where she received a couple weeks of IV antibiotics (to clear up the pin site/ex fix infection), lots of physical therapy, good food, and lots of TLC. The wonderful ortho surgeons from Double Harvest adjusted her ex-fix in early March to provide better alignment of her leg and (hopefully) a better outcome.

Liliane is a mix of emotions---nothing about her is subtle. When she's mad or hurting, you will know it by the extreme volume of her voice. When she dances, she puts everything she has into it---no holding back. When she's happy, she has the warmest, sweetest smile. She's 10 years old but sometimes I look at her and contemplate how both her body and soul have aged in the past 3 months. She's been through a lot.

Today was Liliane's big day--the orthopedic surgeons at Miami/Medishare hospital took off her ex fix under anesthesia. She bravely walked into the OR using her crutches, walking in her characteristic slow, methodical fashion, being careful to avoid jostling her ex fix in any way. She hates IVs, but the CRNA who put hers in today was a pro and did it so quickly Liliane hardly felt it. When she asked me not to leave her while she was asleep under anesthesia, I told her I wouldn't, and I held her hand as she fell asleep.

As she was waking up from anesthesia, I held her hand again. She looked over at me with heavy eyelids. She focused in on my face, and I told her, "Liliane, it's gone, it's gone sweetie." She quickly reached down to her left thigh, felt the soft bandage, realized the bulky, painful, ex fix was gone, and broke into a huge smile. She turned to me, and with an oxygen mask over her nose and mouth (this was on because she was still a little drowsy from the anesthesia), gave me a kiss on the cheek, through the plastic mask. And she continued to smile, as I held back tears.

What a privilege to walk this journey with her.

2 more patients DONE!

2010-04-13T22:27:00.006-05:00

Both of these patients had their casts removed today at Miami field hospital...many thanks to the ortho surgeons who reviewed their x-rays and cleared them to walk again!

Here are their stories:
The girl on the right is 7 years old---her leg was crushed by concrete blocks when a wall fell on it during the quake. She told me that she remembers seeing a bone sticking out of her leg. She was initially brought to a small hospital/clinic in Port au Prince where they cleaned and bandaged her open fracture, but couldn't do much else for her. She was transferred to the US Navy Comfort ship around the 20th of January, where an external fixator was placed for her tib/fib fracture and she had extensive reconstructive surgery to repair the overlying wound. She came to Heartline on February 9th. The plastic surgeons and orthopedic surgeons at MERLIN were a huge help in managing her ex-fix and her open wounds over the subsequent weeks. The ex-fix was eventually removed at MERLIN in late March, and today her cast was removed. She doesn't even need a walking boot at this point--she's been cleared to weight bear as tolerated. Here is what her leg looked like about 6 weeks ago:

She's cleared to be discharged home...but "home" is currently a small patch of land they've claimed in one of the tent cities in Port au Prince, and Dina doesn't want to go home. On this small piece of land they've built a shelter out of tarps. When it rains (like it is right now), their belongings get wet. When the midday sun beats down (like it does nearly every day) the inside of their shelter becomes almost unbearingly hot. Can you blame her for wanting to stay? I love this kid and I can't say no to her...so she's going to stay for at least another week. She's a sweet, funny kid with one of the best laughs I've ever heard. Can you blame me for not wanting her to go? :)

The woman on the left is 45 years old---her leg was crushed by falling blocks in the quake. She initially tried to find care at other hospitals/clinics but was unsuccessful. Our truck found her around the 3rd week in January and brought her back to Heartline. She had a huge open wound overlying her tib/fib fracture. We initially placed her in a partial cast and did extensive wound care. In early February we transferred her to MERLIN where she had an ex-fix placed and extensive skin grafting. She came back to us in mid-February, but then had to go back to MERLIN again in March due to poor wound healing and concerns for infection. After a couple weeks at MERLIN she again came back to us for prolonged IV antibiotics. Eventually her infection cleared. Her ex-fix was removed in late March and she was placed in a cast. Today her x-ray showed decent healing, so the cast was removed--for good. When I told her that this was it----that there would be no more casts and she could go home----she immediately started laughing and hugging us and kissing us. She was so happy. It was beautiful. Her wounds look great. She'll wear a rigid boot during the day for the next month, but other than that, she's done. Here is what her ankle looked like about 9 weeks ago:

re-post from Barbie Bee

2010-04-09T23:10:00.002-05:00

From Jen:
Sorry, lots of re-posting tonight...but this is beautiful! I will try to post some video of our physical therapy dance parties sometime, but the videos won't do it justice. Hopefully Barbie's words convey some of what we did today. It was one of the coolest things I've ever seen.

Earlier today we were laughing about Barbie's Facebook status update, which was as follows:
"'I was so brave!' -- Demi Moore, on her amazing courage at posing naked on the front of a magazine. Respectfully, Demi, that is the most moronic, self-absorbed, obnoxious, mis-use of the world "brave" in the history of humanity. Congratulation. You win."

Barbie's observations are so very true. Demi's definition of brave is absurd. Our patients here are the epitome of brave.

"Survivor" by Barbie Bee:

Go online and search out Destiny's Child "I'm a Survivor". Hook up your speakers, turn the volume on high, with a whole lot of base, and with apologies to your next door neighbors, and rock the house. Then close your eyes and listen to the chorus. And imagine what we saw today...

We were discouraged. We'd lost our physical therapist to a family emergency, and our patients appeared amotivated without his constant encouraging presence. Moods were low. Apathy was setting in. Oppressive heat overwhelmed our tarp covered courtyard hospital. Little six year old Dina, now in a walking cast from her open tib-fib fracture, refused to throw down her crutches and bear weight on it. Afraid. Lillian, 10 year old with an externally fixated femur fracture...crying with each episode of physical therapy, more and more fearful of the pain. 59 year old Leeann, lying stoically in bed 23 hours a day, not exercising her healing leg -- going backwards in progress. Our 76 year old below the knee amputee Genine, needing to learn how to walk again, having a difficult time even standing. 20 year old Amanda, with her paralyzed left arm and shattered left leg, lying sadly and disinterested in her cot, staring blankly into the distance.

We'd hit a stumbling block.

"We just need to get them MOVING..." one nurse said.

"Maybe we could get them to do PT together..." someone else said.

"It needs to be fun," someone else said.

And the idea spiraled. It started from the knowledge of the perhaps little known fact, outside of our hospital, that our Haitian patients have innate and amazing rhythm. And soul. Every night, they sing and clap and stomp together in song in impromptu mass that goes on sometimes for hours. Rocking the house. Rocking the neighborhood over the cinderblock walls, beyond the plastic tarp that is our roof.

And then there was the film "Madagascar," which has been shown here at night projected on a white cotton sheet against the wall. A Disney film in French, about shipwrecked zoo animals landing in the wilds of Madagascar with a bunch of lemmings who break out into fabulous song, singing a hip deep base beat, "You got to move it, move it. You've got to move it, move it. You've got to move it, move it...MOVE IT!!" Nothing more fabulous than to watch heads start to bob and hands start to sway to the rhythm as all of the patients start to sing along to the beat.

It became obvious that our patients have rhythm.

"Let's make them exercise to "Move it!"" recommended someone else. We all laughed. Then someone said, "No, really!"

No. Really.

Fantastic.

So, somehow it happened that we pulled out the electric sound system used to project movies on the wall at night. And plugged it into Dr. Jen's computer. A quick search of her ITunes files revealed a great assortment of deep beat, hip, rhythmic dance tunes. Including the song, "You all ready for this???!!" -- normally danced to at NFL halftime shows by cheerleaders in skimpy tops and pompoms.

We walked around to each patient and said, "In a minute, we're going to turn on the music, and you will do your PT."

Some patients were assigned a helper. Amputees were given the task -- stand and balance on your strong leg, and try to squat up and down. Bilateral casted patients -- stand up with your walker and balance, then sit back down. Young Dina, who refused to walk without her crutches...when the music starts, you will walk on your cast...with one crutch, not two. Young Lilian, who starts to cry at the idea of physical therapy -- you will stand with your crutches and walk around. Each patient assigned a task. They all looked at us curiously, a little dubiously. A little apathetically. A generalized look that shouted, disinterestedly, "Ok, whatever..."

But then, the magic happened.

This was no circus music. No elevator music. No polka or grandma's parlor music. This was raging urban hip hop, rhythm, with wicked base and deep musical soul. Yes, this music required apologies to the neighbors over the cinderblock walls for its volume. Yes, it perhaps shook a bit of dust off the walls. Yes, it was played like your car stereo when you drive speeding down the highway with the volume cranked, bass turned all the way up. Because on the count of three, when Renauld our interpretor turned DJ hit "PLAY", at two in the boring afternoon at our Haitian Field Hospital, he literally rocked the house.

"YOU ALL READY FOR THIS????" the song called, followed by the deep rhythmic beat of sound. Sound which suddenly forced patient's eyes open, pulled giant smiles from their mouths. Heads began to bob. Feet began to tap. Eyes afire with life as the sound system blared its rhythm across the courtyard. I helped our 76 year old amputee onto her one leg. Her shoulders started to sway in rhythm. A smile crinkled her aged, wrinkled cheeks. 10 year old Lillian, afraid to stand, threw down her crutches and danced with her hips swaying and arms undulating rhythmically, balancing crutchless for the first time. Dina marched to the beat on her casted foot. Amanda lay in her cot, brilliant smile, rhythmically rolling her shoulder to the beat. Song after song, shining smile after smile. Little Emmanuel, 3 year old boy with the crushed face, stood in the center of the courtyard and danced. Smiles and rhythm of joy. Old and the young. Nurses and patients and translators and visitors. Rocked the house.

Then the last song, I'm a Survivor, by Destiny's Child, began to play. I paused as I stood in the middle of the courtyard, slowly turning around to see the patients dancing and swaying and squatting and bending and smiling -- incidental physical therapy amidst the endorphin releasing joy of blaring song. Dancing like they were 16 again...perfect...whole...young...strong...in their bedroom secretly in front of their mirror. In a club. At a rock concert. A better day. A freer, more innocent day. Rebelliously blaring the music.... The deep, strong African American female voice pounded forcefully from the speaker in front of me. With each lyric, my eyes glanced off of each patient...their stories of survival...of pain...of endurance...of recovery...of spiritual resilience...flashed into my mind. Fabulous...

I'm a survivor...
I'm not gonna give up...
I'm not gon' stop...
I'm gonna work harder...
I'm a survivor...
I'm gonna make it..
I will survive...
Keep on survivin'....
I'm a survivor...
I'm not gonna give up...
I'm not gon' stop...
I'm gonna work harder...
I'm a survivor...
I'm gonna make it...
I will survive....
Keep on survivin'...

re-post from Beth McHoul: Nadia

2010-04-09T21:58:00.003-05:00

By: Beth McHoul

She's sad. Her name is Nadia and she has been coming to our prenatal program since the earthquake. She is striking because of her tiny form, barely one hundred pounds and her skin is swirly shades of light and dark. Zebra like almost. At first glance I wondered if she had been burned, then I thought a fungus, then I realized it was neither and I have no idea what this is. When I questioned her about it she said her dad cursed her mom with a voodoo curse when the mom was pregnant with Nadia and she has borne the consequences with her stripped skin. Being an albino, handicapped, or different looking is indeed a curse in Haiti as folks can be unkind. Haitian folks often state the obvious. "You're fat" they may state to an obese American. Like we don't have mirrors and needed the reminder. People are often brutal to the broken, the different, the lame. Now we have thousands more due to the earthquake.

Nadia had been coming weekly for her check ups. After her last check up she hung around the door refusing to leave. She said she was waiting for a friend to finish up - the friend finished and left. Nadia was still standing there - waiting. Nadia was needy, lost, young, and hurting. At 21 she is a single mom going it alone. Seems very alone.

I got a middle of the night call the other night from Jonna. Nadia and two men were at the women's center gate with a baby and placenta wrapped in a dirty blanket. Mom had delivered in the street on her way to us. The men, neighbors, were very helpful, dropped them off to us and left. Jonna wrapped baby up nicely and started on postpartum care. I arrived as quickly as possible and joined in on her care. Nadia is extremely anemic, was dehydrated and needed an IV. She panicked and refused so vehemently that it made the drip impossible. I wondered what had caused such fear. Such irrational fear even when I explained how much she needed it and it would only poke for a second. No go.

After 12 hours of care and no guests a Tap Tap arrived to take her home. I was finishing up vitals as the horn kept beeping causing her to speed out the door. The driver didn't seem patient about a new mom trying to get down a flight of stairs with a newborn. So, where's home I ask. She lives in a field under a tent made of sheets. She has another child with her and another in an orphanage somewhere.

Baby seemed fine, mom seemed okay so off they went in the dirty Tap Tap to a squatters field. That night I woke up with a start to the sound of pouring rain. Not just a little rain but a soaking, muddy, fill the streets with huge puddles kind of rain. I thought of Nadia with that unnamed newborn in a tent made of sheets. I felt sick.

Jonna and I had given such good care, wrapped him in new clothes, new blankets and now he must be soaked.
Sure enough Nadia showed up for her first postpartum visit. She looked tired. Silly me asked if she got any rest and she said no, she stayed awake all night protecting the baby. From the rain I asked? No, she said, from the werewolves. Oh. We gave her a tent donated from one of our visiting nurses. Waterproof I pray. We gave her money and sent her off again as baby and mom seemed sad and weary but okay.

Back again she comes for her second postpartum visit. This time she is sick, complaining, crying and has a fever. Over to our hospital she goes to the tender care of Jen and Barbie. This time we have gained enough trust that she submits to an IV although not without much drama and wailing. Djenie and Kenny are her roommates. They are back, not because they need to be - because they want to be. Djenie loves having roommates to snitch on if they are not breast feeding enough or breaking some other rule. Often ones she breaks herself but when busted for that she just giggles. Nadia melts into her cot, goes to sleep and maybe finds some rest from her waking nightmare called life.

Our hospital is made up of this odd mix of wounded and sick people. We watch them morph into members of a community socializing, being silly and enjoying themselves. They drink in the nightly church services the Haitian pastor brings. The kids do puzzles, tease the nurses, and beg to listen to I Pods. Hopefully this will happen as Nadia's body heals so will her soul. A fever might have been the best thing that could happen to her because it brought her to our hospital. I pray as her body heals her spirit will open and she will find healing at our hospital, our place of refuge. Jesus always touched the Nadia's - the beaten down and lost is His specialty. Darkness to light. Brokenness to healing. From terror to safety. God does all those things - I pray we will see them in Nadia.

back in Haiti...again

2010-04-08T23:09:00.005-05:00

I never felt good about leaving on 3/23, but I needed to get back to Minnesota due to work commitments. Shortly after arriving I spoke with my boss at length and got his permission to come back to Haiti for the month of April. Many people I work with again stepped in to cover my shifts, and for that I'm extremely grateful.

Part of the reason leaving was so hard is because from day one we've been committed to taking care of all of the earthquake-injured patients who came through our doors (or who we found in the streets, or who were sent to us from an assortment of other hospitals/organizations), and that work isn't done yet. The most inpatients we've ever had is around 35. Tonight we still have 24. Not all of them have earthquake injuries, but most do. At this point, most are here to receive ongoing physical therapy, strength training, wound care, and so on. I feel a very strong commitment to this organization, and to these patients, and I want to do everything I can to help finish out the work we've been doing since the earthquake.

We still have patients in external fixators, including one young woman who just had her ex-fix placed a little over a week ago at MERLIN, to stabilize her tib/fib fracture, sustained in the earthquake, that hadn't healed at all. When Barbie (our awesome physician assistant from Alaska who's been working with us since February) took her cast off in the field, the fracture site was completely mobile--10+ weeks after the earthquake. So for her, it's like she's just starting the whole healing process now. She's not going to stay inpatient the whole time, but she'll require lots of ongoing follow up care over the next couple months that needs to be coordinated.

Speaking of Barbie, if you're not yet reading her blog, you should be. She is an amazing writer and has been documenting many of our patient's stories here.

Coordinating care has become more difficult recently, as many relief organizations are leaving. On a purely gut level this frustrates me to no end. I know that decisions are being made taking into account variables that I'm not aware of. I get that. And I know that post-disaster medical relief is exactly that---relief. It's not necessarily supposed to be around forever. And we're going to be shifting gears away from treating injuries as well, once all of our current patients are taken care of.

But even though I "get" it, it's still hard to be here on the ground watching our referral sources leave. Just being honest. I will say this---the people from these organizations who are here are amazing. They don't want to leave. So many have been working so hard for months now. And the fact that they have to leave doesn't in any way negate all the amazing work they've already done. The work we're doing here at Heartline would have been impossible without being able to coordinate with many other organization. To everyone at Double Harvest, the USNS Comfort, MERLIN, and the University of Miami/Medishare hospital who have partnered with us over the past few months and provided surgical care for our patients---thank you, thank you, thank you.

We still have some options, and in the end it's going to work out, one way or another. And for the few patients we have who need a higher level of care than what can be provided in Haiti, we're working with two great organizations to secure free surgical care in the United States. Once the doctors and hospital facilities agree to do the surgery for free, we will work on obtaining medical visas for these patients. I'm hoping they can be to the U.S. by early summer.

Another recent development is that several of our patients are closer to walking on their new prosthetic legs! We're working with Handicap International, a great organization based out of Europe. Two of our patients had their first fitting today. It was very cool to watch people from this organization work with patients as they walked on two legs for the first time since the quake. You can read more about one of our patients (Emmanuel) on the Livesay blog here.

One final thought for tonight--from the beginning, we've dealt with the semi-impossible task of discharging patients who no longer have anything even minimally resembling a dwelling to go home to. Almost every day I have conversations with patients, trying to figure out where they're staying, what they have, what they need, and what we can provide for them. All of our patients who'd recently received care at MERLIN received a tent, mosquito nets, cooking set, water bag, hygiene items, and a bag of rice---that will all be a huge help for these families. For the non-MERLIN patients, it's trickier. We have a few new tents and tarps (thanks Betty!!), some bed frames and cots, bags of food, clothing, and other things we can distribute. The biggest issue is not having enough tents. When everyone is living outside, how do you decide who "most" needs a tent?

I'm off to bed. The days here are still long, but they are good. It is a privilege to work with these amazingly strong, brave patients---whether that entails putting in an IV, dressing wounds, coordinating medical visas, escorting patients to other medical facilities and consulting with surgical specialists, translating, working with other skilled and compassionate medical providers, ordering medications, assisting with physical therapy, organizing supplies, coordinating discharge plans, or reading a book to some of the hospitalized kids.

From Barbie @ Heartline Hospital--Please help us find a neurosurgeon

2010-04-02T00:48:00.002-05:00

Amanda, a 22 year old young woman living at the Heartline Field Hospital in Port au Prince, Haiti, was crushed when her neighbor’s house collapsed into hers in the Haiti earthquake on 12 January 2010. She has multiple injuries, including a severe nerve (brachial plexus) injury which causes her to live in incapacitating pain. There are no specialists in Haiti who can perform this repair. We are seeking help to get Amanda to the United States (or elsewhere) to a neurosurgeon/ brachial plexus specialist, in a last hope effort to resolve this young woman’s incapacitating pain. If you know any orthopedists or neurosurgeons, please share Amanda’s story with them, and see if they know anyone who might be able to help Amanda. We are asking that the surgeon and treating hospital donate their services. If and when a surgical team is identified, we will also need financial donations to pay for Amanda’s medevac to the United States, and her room and board while she is there. Amanda has a passport, which will facilitate her travel out of the country.

Here is Amanda’s story:

On the evening of 12 January 2010, young Amanda was standing in her mother’s kitchen outside of Port au Prince. When the earthquake hit, her neighbor’s house came crashing down into hers, trapping Amanda under its crushing weight. Her neighbor – Amanda’s best friend – was killed instantaneously. Earthquake survivors describe the shaking and grinding of the earth on that day as horrific and surreal; many believed the world was coming to an end. In the minutes after the large quake, neighborhoods were filled with the sounds of thousands of screams – some crying out in pain, others calling desperately for their crushed loved ones. The sound of screaming echoed eerily and incessantly into the dark night, through the near and distant neighborhoods; they could reportedly be heard for miles. One in every ten people in Port au Prince and the outlying communities was killed in the earthquake that shook for less than one minute.

Amanda’s screams of pain were heard by neighbors, who worked aggressively through severe aftershocks to free her from the concrete and rebar rubble which pinned her. When she was finally rescued, it was evident that her life was in danger. Her left arm and femur were crushed – both exquisitely painful, with large open wounds; the latter – her deformed femur -- was potentially life threatening. In the United States, such severe injuries would get Amanda life-flighted by helicopter to the nearest trauma center for emergency surgery. In Haiti in the week following the earthquake, Amanda was one of more than 100,000 severely injured individuals desperate – and unable – to find care.

Imagine if this were your daughter, your sister, or your friend. And you are desperately trying to find her care. You drive first to your local hospital – which is absolutely overwhelmed. She is there for two days, and receives an IV, but no pain medications and no orthopedic care. She is in agony, with a deformed femur and an open fracture of her arm. You become desperate; you decide to drive her to the city. Certainly there, at one of the big hospitals, she will receive help. But many of the big hospitals, you soon discover -- to your horror -- have been destroyed. You find one – hospital number two – and take her there. After a day, she again receives no care. You drag her unsplinted, broken form in search of a rumored orthopedic field hospital. You cannot find it, so you sleep with her in the streets, cradling her crying form through the night in your arms. In the morning, you take her to hospital number three. No care. You search again for the rumored field hospital and finally move her again – still unsplinted, still without pain medication, to hospital number four. There, she is loaded into a truck and convoyed across the countryside – still without pain medication and still unsplinted, every jolt on the country highway causing exquisite bone on bone grinding – to the Dominican Republic, the country east of Haiti, to hospital number five. There she finally sees an orthopedist, who places a metallic external fixator into the shattered bones of her left femur and a metal rod to stabilize the open fracture of her upper left arm. There they discover that her left arm is paralyzed, yet in the cruel irony that is severe nerve injury, her arm is not numb, but instead burning with severe, intractable nerve pain. And she develops a severe infection at the surgical site of her left arm. You meet a representative of another field hospital located back in Haiti, that has orthopedists and plastic surgeons, and can manage her open wounds and infections. So, you truck young Amanda, once again, over the bumpy rural highway, back to Port au Prince, the city from which you started, to hospital number six -- Merlin Field Hospital. There, in a collection of canvas tents on an old tennis court, European physicians place skin grafts over her open wounds of her left leg, and further manage her infection. You discover that they, too, are overwhelmed with patients, and recommend transferring her to hospital number seven – Heartline Field Hospital – for pain and infection management and rehabilitation. At Heartline, it becomes obvious that the nerve pain in her arm is severe and unremitting; so she is transferred temporarily to Miami Field Hospital – hospital number eight -- where an anesthesiologist places a temporary catheter into her chest through which pain medication can be infused to blunt the nerve pain in her now non-functional left arm. This is a time intensive infusion, done over 30 minutes three times a day. She is then transferred back to Heartline for regular care and rehab; there, her pain management catheter is found to be ineffective. Her unremitting pain continues. Imagine this is your sister, your daughter, your friend. The agony of her journey. The agony of months of intractable pain. The overwhelming hopelessness.

While Amanda’s femur is slowly healing, her arm pain remains severe. The unfair irony of Amanda's arm injury -- a probable stretch or tear of the brachial plexus -- is that although the nerves to her arm now fail to function, and it hangs limp and unusable at her side, she is plagued not with arm numbness, but with severe, incessant pain. Nerve pain. Imagine the worst ice cream headache of your life. Or the worst sciatica of your life. Imagine the pain you get when the dentist pokes his metal hook right into that sensitive part of your tooth. Fiery, electrical, intolerable pain. That is nerve pain. Now, imagine living with that constant pain, with no hope for relief. This is Amanda’s burden.

Some have proposed an amputation of her arm. The problem with this solution is the arm can be removed, but the nerve pain -- coming from higher up, near her neck -- will persist. After such disfiguring surgery, she would still feel severe, phantom pain into the tips of her fingers -- even if her arm were no longer there.

There is a possible surgical intervention for Amanda. But there is no one in Haiti trained to perform it. There are a few specialists in the United States who can. But the clock is ticking. The farther she gets from the injury, the less likely the injury can be successfully repaired. And the more likely this young 20 year old woman will live with ongoing, devastating pain. As one orthopedist bluntly put it, "This injury will not kill her. But suicide, from the ongoing, unremitting pain, could."

Please help Amanda. We need to find her a surgeon. And we need the funding to get her to the United States, and support her while she is there.

If you can help in any way – be it a donation, an offer of housing or transportation, or a medical contact, please contact Heartline Ministries at helphaitiamanda@yahoo.com. Together, we believe the Heartline Field Hospital community and contacts can come together to find Amanda a final solution – at hospital number nine. We will keep you informed of our progress to find Amanda care.

Please forward this request on to anyone you feel might help with Amanda’s case.

Heartline Field Hospital, Heartline Ministries, Port au Prince, Haiti

helphaitiamanda@yahoo.com

back in Minnesota

2010-03-29T23:17:00.011-05:00

I've been back in Minnesota for a week now---my body is physically here but my mind and heart are certainly elsewhere!

THANK YOU, so much, to everyone who donated money/medications/supplies, donated their time, prayed, sent encouraging messages, left encouraging comments, and everything else. Many thanks as well to colleagues at Children's who covered shifts for me. I really appreciate all of the support!

I'm working on Part 3 of the Heartline story...coming soon.

I've recently posted some videos from Heartline on YouTube, including footage from the hospital and around Port au Prince:

Patient walking for the first time since the quake

English lessons with hospital kiddos

Hospital church service

Singing with hospital kids

Tent cities near Cite Soleil

Delmas 33 area tent city

Nazon neighborhood of Port au Prince

Delmas 33 area damage

I was originally planning to leave Haiti on 3/21. However, a couple days before my planned departure, the opportunity came up to bring Collette home. She lives about a 2 hour drive south of Port au Prince. Collette was one of our first patients back on 1/18. You can read her story on the Livesay's blog here and here and here. She went to the Comfort ship for treatment of her pelvic and femur fractures, then came back to Heartline for post-op recovery and physical therapy. Her baby was the first born ever on the Comfort. It was an incredible privilege to be able to help her complete her journey. Here are some pictures from the day we brought her home:

tent cities

2010-03-19T07:16:00.009-05:00

There are tent cities everywhere in Port au Prince and the surrounding areas. Recently I've been riding on top of the big truck when we go out to do transports. From up high, you get a very different perspective than when riding in a truck at ground level, as you can see over walls and across landscapes.

The tent cities, some of which were already present when I arrived over 2 months ago, have grown and changed a lot since then. Most are much bigger now than they were previously. Tents and tarps now cover every free inch of open space. And many of them can hardly be considered either, as they are made out of a makeshift assortment of tattered plastic, fabric sheets, pieces of metal, a few sticks, and the like.

Here are some pictures I've taken in the past week or so. Pictures can't capture the vastness of many of the tent cities. Once I'm home and have a faster internet connection, I'll work on uploading some of the video I've taken.

a great way to end a long day

2010-03-15T07:52:00.004-05:00

falling asleep holding Antoinett's miracle baby...with a Haitian church service going on in the background

with the passage of time

2010-03-13T00:30:00.001-06:00

(we are Haiti)

Watching people come full circle has been one of the greatest things I've been able to experience by being here since (almost) the beginning. Little by little, people who came to us very early with horrible wounds are having their very last dressing change, people with severe fractures are having their casts removed and are starting to walk again, and people with external fixators in place have tenative dates for their final removal.

A few days ago, a woman just a few years younger than me came through the gate. Like many others before her, she looked at me with recognition, and I looked at her, flipping through the rolodex of faces in my mind, trying to place her. She told me her name and story and it clicked--she'd made it to our makeshift ER (I believe we picked her up on our truck in one of the slums) on Saturday, January 24th, with a presumed pelvic fracture and hematuria--a concerning combination. We brought her to Terminal Varreux and she was accepted for transfer to the USNS Comfort the same day. I hadn't seen her since then. She's had an external fixator ("ex-fix"--it's lot of metal bars and screws) across the front of her pelvis for the past 6 weeks. She's amazing--still smiling and upbeat after 6 weeks of pretty constant pain and difficulty moving. We took her to Double Harvest Hospital up near Croix-des-Bouquets. They want to wait another 2-3 weeks, and then take off the hardware. I know she was hoping to have all the hardware removed that day, but she understands why she has to wait. It's a bummer I won't be here to watch her get the ex-fix taken off--I would have loved to see that.

The people at Double Harvest Hospital have been absolutely wonderful to work with. Over the past week, we've brought them 20 patients who needed x-rays and orthopedic consultation. The 2 ortho surgeons, Dr. Steve and Dr. Pete, have hearts of gold. Even though we showed up late in the afternoon each day with a truck full of patients, they were always genuinely happy to see us and were so eager and willing to help. It's because of their help and expertise that we've been able to tell many people this past week: "You're done! You can walk again. Everything is healing well." They're both leaving tomorrow morning and they will be missed (thankfully there are other ortho docs coming in from Michigan). Dr. Steve and Dr. Pete revised & adjusted the ex-fix on a 10 year old girl with a femur fracture. They'd initially said there wasn't anything they could do to improve her outcome (her leg was rotated internally), but they mulled it over and decided they needed to try, and the outcome was great. Because of their effort, once her ex-fix comes off in a couple weeks, she'll walk better than she otherwise would have. Thanks Dr. Pete and Dr. Steve!!

Barbie (super awesome ER PA from Alaska who's been here for a month and will be staying through April to finish things out) with Dr. Steve, cutting off Berlancia's cast

Other recent things:
--Tara, Beth, and I were together at the births of 2 baby girls a few days ago. One baby was born around 2:30 PM, and the other around 2:30 AM. Tara and Beth were with the moms constantly for over 24 hours straight. I was able to get a little sleep, as they only woke me up right when the baby was being delivered. Both babies did great. It was SO fun for the 3 of us to work together on these 2 births. Tara left later that day and Beth & I are missing her like crazy.

At Double Harvest on top of our transport truck, on a very unseasonably chilly day

--One of the babies Beth delivered early Wednesday morning was brought back today for her scheduled 3 day check. The baby is unfortunately pretty sick--she has a high fever, jaundice, and is dehydrated. We've got her on IV fluids and IV antibiotics, and will keep her for at least a week to give her a full course of IV antibiotics. We don't have the ability to do things like blood cultures, so we'll give a full course of antibiotic treatment to be safe.

--We still have about 25 inpatients. Most are here mainly for intensive physical therapy (many thanks to our recent PTs Shelly and Ruth, and current PT Brian, who returned on Wednesday after already spending 2 weeks with us back in February), though a number of people still require dressing changes, and we've got 8 people on IV antibiotics around the clock to treat a variety of infections. Between the 8 of them, they're receiving 35 doses of IV antibiotics per day. It definitely keeps the nurses busy. Several of these people on IV antibiotics are being treated for infections related to orthopedic injuries---2 months after the injuries were sustained in the quake.

--Winnie is a Haitian nurse who showed up the day we opened (January 18th) and offered to help. She's been an amazing addition to our team--she is very talented and caring. One of our patients on IV antibiotics is a little 10 year old guy who sustained a horrible crush injury to his face during the quake, but didn't get any care for a month. By the time he made it to the hospital, he had a huge facial/orbital abscess full of botfly larvae. He's required multiple surgeries and over a month of IV antibiotics and anti-fungals. That means he's required many, many IVs. He's such a brave kid and usually does well with getting a new IV put in, but today it was too much for him. At one point I looked over and Winnie was holding him, comforting him, talking to him, calming him down. She is so good with the kids here. And anytime we can hire someone locally, I'm all in favor of it--it provides someone with a job and an income, and we get to work with someone who completely understand the language and culture of the people we're serving.

Winnie with Dina, another one of our patients

--We continue to work closely with MERLIN, a UK-based medical relief organization. I've lost count of the number of skin grafts they've done on our patients. We've got a great system going with them---we typically take patients back to Heartline within a day or two after their surgery, and they send a team out to us twice a week to do all of their dressing changes. It works out great. I've learned more about skin grafts in the past 2 months than I probably would have learned throughout my entire career in the states.

Merlin nurse examining Dina, a girl who had an open tibia fracture and gaping overlying wound...her ex-fix should come off in the next week or two

Healing skin graft

Healing skin graft donor site

--Tonight there was a huge crowd of people outside the hospital gate. Apparently someone (or some organizatino) is doing a food distribution tomorrow morning, and people were lining up tonight in anticipation of the distribution. I've heard about what's happened at other food distribution sites around the city--here's to hoping tomorrow is relatively peaceful outside our gates.

--I'm more and more aware these days of what a privilege it's been to have been a part of something like this. Over the past week I've finally had time to just sit and talk to some of our patients at length. I've talked to all of them to some degree over the past weeks, but this is the first time I've been able to spend lots of uninterrupted time with them. Their stories are amazing, heartbreaking, and every other emotion you can imagine. I will miss these people like crazy. It is going to be very hard to leave Haiti...

there is hope--part 2

2010-03-06T21:56:00.002-06:00

You can read part one here.

On Monday, January 18th, 6 days after the quake, Heartline clinic opened. John McHoul, Troy Livesay, Don Buxman, and Byron Tlucek are all Heartline missionaries who live in Haiti. Since the quake, they'd been around the city and had a good idea of where the injured were gathering. By day 6 there were some clinics and hospitals taking care of the injured, but everyone was overwhelmed. Everyone was turning away patients due to lack of supplies, medications, and space. Many of our patients tell stories about how they were turned away multiple times before they finally found medical care. Some never did. One dad told us how he'd taken his son, who had a crushed foot, to 4 different clinics/hospitals in Port au Prince, and he was turned away by each one. Finally, he made his way to Zanmi Lasante, the Partners in Health hospital in Cange (in central Haiti) about a week after the quake, and by then his son's leg needed to be amputated in order to save his life. Of course there is no way to know whether or not his son's leg could have been saved if he'd received medical attention sooner. And I don't blame any of the clinics that sent him away--like I said, everyone was overwhelmed and everyone had to make hard triage decisions.

Heartline operates out of several houses in Tabarre, a section of Port au Prince located about two miles from the main airport. It is not in a location that lends itself particularly well to taking care of walk-in patients, especially injured patients. For that reason, the decision was made early on that we would go out into the city (with large trucks) and find the most severely injured patients. During the first couple weeks, Heartline's trucks made about three trips a day out into the city, bringing back many critically injured patients on each trip.

Pre-earthquake, Heartline ran several programs for women, including prenatal classes, prenatal medical appointments, and a birthing program. Most of these programs are run out of one of Heartline's houses in Tabarre, which is not far from the airport. About a year ago, Heartline decided to offer prenatal classes and appointments in Simon Pele, a slum near downtown Port au Prince. After the earthquake, this was one of the first places Heartline's on-the-ground team visited. They found a large number of injured people at a clinic run by the brothers of charity. They were doing their best with a small number of medical supplies, but they did not have any doctors or nurses. Our first patients came from this clinic in Simon Pele (or Pele for short), and to this day we continue to visit this same slum three days a week and continue to take care of ill and injured patients from Pele.

As the patients arrived back at Heartline, they were quickly triaged based on the severity of their injuires. Those with the most severe injuries were brought inside and seen by a doctor and nurse immediately. Treatment for those with less severe injuries started outside in the clinic/ER's front "yard", which we'd transformed into a well-stocked wound care station. As space was available inside, these patients were transferred inside for more definitive care, including sedated wound debridements, laceration revisions, open and closed fracture reductions, amputations, splinting and casting, and abscess incision and drainage.

We worked in teams and we were in constant consultations with each other. The doctors, nurses, and other support personnel (medical and non-medical) were all amazing. Lori Moise, a nurse from Real Hope For Haiti worked with us for much of that first week and was a huge help. She’s lived in Haiti for 15 years and nothing fazes her. John Ackerman, another long-term Haiti missionary and nurse, also stepped in to help during the first several weeks. Many others who were here during the quake also helped out from day one. In addition to the drivers/go-anywhere do-anything guys mentioned above, Jonna Howard (midwife), Joanna Thiele (RN), Beth McHoul (midwife), Tara Livesay (go-anywhere, do-anything person & translator), Nikki Skovron-Filostin (amazing translator), Lisa Buxman (midwife), and Vivien Ingram (EMT) all played a huge role. John and Beth's daughter Morgan (RN and translator) and her boyfriend Tony (paramedic) also arrived on the first charter flight and worked hard throughout that first week. Karen and Tim (both are adoptive parents, and Tim is a paramedic) were an integral part of the team that first week. Dr. Tami Rice (anesthesiologist) and her husband Robert (another go-anywhere, do-anything guy and videographer) flew in on that first flight and spent a week here. The other doctors included Dr. Joe Boyle (emergency medicine) and Dr. Tom McKnight (family practice). It all came together somewhat haphazardly, but in hindsight, the mix of people we had those first few days was perfect.

As I've mentioned before, it felt incredibly gratifying to be able to provide sedation, analgesia, and anesthesia for all patients undergoing painful procedures (most of whom had not yet received any pain medication for their injuries). In a country in which people suffer many injustices, this felt like justice.

Near the end of our first week, two amazing paramedics from New York City (Rhona and Chris) arrived via the Dominican Republic. They transformed the way we conducted the truck runs into the city and raised the level of pre-hospital care we were providing. They instituted a system of early administration of IV fluids, early treatment of pain, early basic treatment of wounds, and pre-hospital triage. With their leadership, truckloads of patients began arriving with IVs in place, pain meds administered, and injuries/illnesses labeled on a piece of tape on their clothing. This expedited our treatment of the ill and injured once they arrived at Heartline.

Along with all of the hands-on medical work, I (along with some others) started working the administrative side almost immediately after the clinic/ER opened. This wasn't a huge surprise, but it did require me to change my thinking a little. It meant that my laptop (and later, an International Blackberry sent from Providence with Greg Erickson) became essential parts of the work we were doing. Coordinating patient care, arranging patient transfers to other hospitals, helping recruit and schedule volunteers, organizing, re-stocking, and taking inventory of supplies, negotiating for supplies and medications, and so on---all of this occurred daily.

Next up: procuring supplies, collaborating with other organizations, developing an inpatient ward

today

2010-02-27T21:06:00.008-06:00

Tara, Beth and I were invited to visit the USNS Comfort ship today. I've been in close contact with them since their arrival here in Haiti. They took many of our critically injured patients during the first couple weeks after the quake. Since then, we've taken many of their post-operative patients at Heartline so they can receive ongoing post-op care. It's been a cool partnership.

It was a privilege to meet some wonderful Navy personnel (doctors, nurses, a midwife, and others) who've been working 18+ hour days taking care of 100s of patients. They've performed over 800 surgeries since arriving in Haiti on January 19th.

Today their very last patient left the ship and came back to Heartline for ongoing care (he'll be on IV antibiotics for the next 2 weeks and may need follow up surgery). We brought some of the very first patient to the ship back in mid-January, and took the last one off today. Today felt as surreal as some of the first days here. But in a more hopeful way. Tara blogged about our day here. She summarized the day perfectly.

thank you!

2010-02-23T22:27:00.004-06:00

I was originally planning to be in Haiti (and away from my regular work) for about 5-6 weeks. For anyone counting, that means I should be leaving right about now.

But due to the generosity of my bosses, co-fellows, and co-workers, I will be staying through the third week in March!

I started thinking about staying longer near the beginning of my time here. As time went on, it was something that was on my mind every day. I was very hesitant to ask for more time away, mainly because many people had already volunteered to cover my January shifts (I was already scheduled to be away for the month of February so I didn't have any shifts scheduled for this month) and I didn't want anyone to feel like I was taking advantage of their generosity.

A little over a week ago, despite my hesitations, I finally just asked to have more time away. And within a few days all of my shifts through the first 3 weeks of March were covered. That is a huge relief.

To all of my co-workers, mentors, and teachers (at Children's and at the University of Minnesota) and to everyone who has donated money, supplies, medications, and time (whether in Haiti or in the U.S. covering for colleagues who are in Haiti)---THANK YOU so much for all that you are doing. You are playing just as much of a role in Haiti earthquake relief as those of us who are here, and for that I am very, very grateful. I owe you all big time :)

reuniting!

2010-02-21T09:53:00.004-06:00

Over the past week we've seen two kids reunited with their parents. Both of the kids received excellent care onboard the USNS Comfort ship. They came to us for post-op care.

This first little guy had a rough first week with us. He has a femur fracture and his whole leg is in a cast. One night, he started saying there were bugs under his cast. Within a few minutes, he was screaming and was inconsolable and had to be held down by many people and given some sedative medications so his cast could be cut off. Our orthopedic physician assistant Kevin put on a new cast, and then "bi-valved" it (cut all the way down both sides) so that the cast could be removed if he got scared again. Kevin then wrapped the whole bi-valved cast in Ace wraps to keep it in place. This whole arrangement worked out really well. Over the coming days, this little guy would ask to have his cast removed once or twice a day. We would put him on a bed or table, carefully removed the cast, and let him gently touch his leg, apply lotion to his leg, and just see that everything was okay.

In the meantime, several people were working on finding his dad. Lisa Hojara took him out into Port au Prince to see if he would recognize anything. Eventually, Lisa and Ryan, one of our nurses, took him to one of the Haitian TV stations. They interviewed him and aired the interview that night. The next day, his dad walked into Heartline Hospital. The smile on this boy's face was indescribable. His dad's smile was just as wide. Dad told me he hadn't seen his son in about a month. Watching dad interact with his son was very very cool.

The second child reunited with her family is a 9 year old girl with a severe pelvis fracture. Her dad was with her during her first days on the ship, but he then needed to leave and go back to work. He hadn't been back to the ship since that time. She hadn't seen her dad in several weeks, and hadn't seen her mom for longer than that. She is from an area about a 3 hour drive from Port au Prince. We didn't have phone numbers for anyone in the family, but we did have names and addresses. We were planning to wait a week to see if her dad came to see her, and if not, we were going to try to find her family.

Because of the severity of her fracture, this little gal needs to be "non weight bearing" (she's not allowed to walk) for the next couple weeks so her pelvis can heal. She's got a ton of energy and wants to walk very badly...we are constantly reminding her to stay in her bed!!

A few days ago, as I walked through the hospital, this little gal called over to me repeatedly, trying to get my attention. I was busy so it took me awhile to get to her. Once I got there, she gave me a huge smile and said "This is my mom!!" Her mom had gone to the onshore contact place for the Comfort looking for her daughter, and they'd directed her to us. Another very happy reunion.

(mom on the right and her daughter in the middle)

(the 2 girls on the left were patients together on the Comfort and now patients together at Heartline; the girl on the right is the sister of one of our other patients)

there is hope--part 1

2010-02-21T09:51:00.002-06:00

(I'm writing a series of posts on Providence's blog describing the past 5+ weeks. Here is the first part)

I'm going to write a series of posts describing how, from my perspective, I ended up helping run a field hospital in Haiti. It's not something I ever thought I'd do. But there is no where else I'd rather be, and nothing else I'd rather be doing, at this moment in my life.

I arrived in Haiti on Sunday, January 17th--five days after the earthquake. Heartline Hospital & Clinic opened up the next day. Five and a half weeks have now passed since the earthquake, and January 11th, the last time life felt relatively normal for me, feels like a year ago. To fully describe the past month and a half would be impossible, but I'm going to try.

To start, I want to express my gratitude to each and every person who has prayed, donated money, donated supplies & medications, and donated their time to helping Haiti. This is not a cliche--what we are doing here in Haiti would not be possible without the support that has flowed in from around the world. I truly wish I could thank each person individually. I will try to name as many people as possible in this post and the upcoming posts, but any omission is not intentional. I am simply overwhelmed by the support.

Heartline Ministries has been working in Haiti for the past 20 years. Their ministry has mainly focused on caring for orphaned and abandoned children, facilitating adoptions, and running several programs for women (providing pre-natal care for pregnant women, a birthing program, post-birth educational and child development classes, and a sewing class). Because they've been in Haiti for over 20 years, they know the country well and are well-connected. After the earthquake, they immediately started asking the question: "How can we best help?" Fairly quickly, they decided to focus on providing medical care for some of the thousands of people injured in the quake.

The walls surroundings most of Heartline's buildings/houses sustained major damage, but all of the buildings themselves sustained only minor damage and were safe enough to be occupied. Because of their pre-natal and birthing program, they already had some medical supplies available. Real Hope for Haiti came through big time, delivering hundreds of pounds of medications and supplies to Heartline in the days following the quake. Many people who had been in Haiti since long before the quake (working with Heartline and other associated ministries) worked long hours organizing the clinic, setting up living quarters for the volunteers, and developing a plan for how the clinic would run.

In the meantime, a medical team was coming together in the U.S. All of us have a story about how we made it to Haiti. For me, it started the minute I learned about the earthquake. I had just arrived at work. I got an e-mail on my phone from Tara Livesay. The rest of that night is a blur. I was at work, but I was completely consumed by the magnitude of what had just happened, overwhelmed by the uncertainty of what was to come, and panicked by not knowing if everyone I knew in Haiti was safe. My colleagues at work were very gracious to me that night. They understood when I needed to step away to make a phone call or check my phone for e-mail or text message updates. It's difficult to describe the panic we all felt that first night.

One of my bosses, Dr. Rob Sicoli, happened to be in the ER that night. He told me immediately: "If you can find a way to get to Haiti, you should go help. We will support you." By the following morning, I was already exploring ways to get to Haiti and help. I called Rob and asked if he was serious about what he'd said the night prior. He assured me that he was. I'm currently completing a pediatric emergency medicine fellowship program that is sponsored by both Children's Hospitals and Clinics and the University of Minnesota Department of Pediatrics. In order to go to Haiti, I needed the support of both places, and I received that support in abundance. Dr. Manu Madhok, the fellowship director, and Dr. Mark Roback from the Department of Pediatric Emergency Medicine at the U of MN arranged for my time in Haiti to count towards fellowship requirements so that I didn't need to take any unpaid time off to be here. Dr. Sicoli, along with his co-director, Dr. David Hirschman, helped arrange coverage for my ER shifts.

The days leading up to my departure were a blur of phone calls, e-mails, packing, very little sleep, and an overall feeling of wanting to get to Haiti as quickly as possible. During that time, many of my co-workers at Children's generously offered to cover my ER shifts. My home church, Woodland Hills Church, took up an offering and has raised over $40,000 for Haiti earthquake relief, some of which has helped fund the work we've been doing with Heartline. Providence Ministries covered my travel expenses to Florida and helped purchase essential supplies and medications that we used during those first days. Greg and Marcia Erickson from Providence, along with my parents, cleared their schedules and in the last 24 hours before I left did everything from running errands to packing to cleaning to you name it--they were amazing.

Getting from Minneapolis to Port au Prince was an adventure that included flying to Orlando on Saturday the 16th, landing around 8 PM, driving to Fort Lauderdale in the middle of the night, sorting through thousands of pounds of medications and supplies, trying to decide which ones were the most critical to get to Haiti first (when in reality they were all critical), then flying into Haiti on the morning of the 17th on a 6 seat plane chartered by an organization called Clean the World. I had no previous connection with Clean the World--they generously offered me a seat on their flight. Heartline also chartered their first flight that same morning, loaded up with several of the first medical volunteers, along with thousands of pounds of supplies, medications, and food.

Once arriving in Haiti I met up with Troy and Tara Livesay, some of my best friends. I lived with their family in Haiti back in 2008, and I've been staying in their house since arriving in Haiti last month. It was so good to see them, hug them, and talk to them.

We spent all day Sunday organizing the clinic space, medications/pharmacy, and supplies. By the end of the day, we were ready to go. We opened the clinic on Monday the 18th, six days after the quake. We had four doctors (myself, an emergency medicine physician, an anesthesiologist, and a family medicine physician), several nurses, a paramedic, and many support personnel. It's unfortunate that people frequently single out the work being done by doctors and nurses for special praise, because the truth is that every single person, medical and non-medical alike, has played an essential role in what we're doing.

Next up: 1st and 2nd weeks of clinic & Minnesota connections

another patient comes full circle

2010-02-15T23:13:00.004-06:00

It's too late, and I'm beyond tired, but I need to share this.

Another of the original 11 we sent to the USNS Comfort came back tonight. She is a beautiful, amazing, strong, courageous 18 year old girl who came to us on January 18th or 19th with a closed right femur fracture. She was on the 2nd floor of a house during the earthquake. She tried to run out of the house but wasn't able to make it before the house started falling down all around her. A wall fell on her thigh, fracturing her leg. She was pulled from the rubble the same day as the quake. Prior to us finding her and bringing her to Heartline, she told me she'd been brought to various other hospitals, but, as she says, "because I wasn't bleeding and I didn't look that bad", she was overlooked. Given the severity of the injuries seen during those first few days, I can certainly imagine that happening.

We brought her to Terminal Varreux on January 20th, and she was taken that same day on board the USNS Comfort. On each trip, the helicoptor pilots took about 3 injured patients from Terminal Varreux to the ship, and I think she was in the 3rd group. Each trip took 15-20 minutes, so she had to wait awhile. As she laid on a stretcher on the ground, I knelt down next to her, held her hand, and talked to her about what was going to happen. She was so sweet, so calm, and so brave. Finally it was her turn. The Navy personnel picked up her stretcher and carried her off. I cried tears of relief as the helicoptor took off.

She received incredible care on board the USNS Comfort. She was in traction for about 2 weeks, then had surgery to repair the fracture and insert metal rods. She left the ship about a week ago and had been doing okay since then, until yesterday, when she developed severe knee pain and a fever. Her mom died many years ago and her dad isn't around, so she's been staying with some cousins. They brought her to us tonight. Someone said a new patient had just been carried in on a stretcher. I walked out to see her. For a few moments I didn't recognize her. But then I knelt down next to her, felt her burning forehead, watched the tears fall from the corners of her eyes as she cried in pain, and listened as she told me "ou te mete'm nan bato a" (you put me on the boat), saw her paper from the Comfort, and suddenly it all clicked. Oh my gosh...it's hard to describe the emotion of seeing her again.

She is really sick with a fever, severe pain, and some kind of infection. With her previous surgery we're worried that some of the hardware holding her bones together, or the bones/joints themselves, could be infected. We gave her lots of IV fluids, pain medications, strong IV antibiotics, and a lot of TLC. She's feeling a little better, and looking a little better. I've already been in contact with some orthopedic surgeons at a hospital not far from us, and we might need to transfer her tomorrow depending on how she's going. Despite her obvious pain and suffering, she was still so appreciative of everything we were doing. I can't count the number of times she said thank you. She also spoke very highly of her time on the Comfort. What a privilege to be able to take care of her.

One other thing--we went to pick up two post-op Comfort patients from Terminal Varreux on Sunday. The day prior, the discharge coordinator had asked me (via e-mail) if there were any supplies I needed. I e-mailed back a fairly short list of some very specific things we were looking for. Less than 12 hours later, we were there to pick up the patients. As soon as we pulled up, 3 or 4 military personnel came walking up to the truck carrying boxes with "Heartline Jen Halverson" written on them. Once we got back to the hospital, I opened up the boxes, and they contained almost everything I'd asked for---rapid malaria test kits, Heparin, Luer lock syringes, 100 mL bags of saline, IV fluids, ultrasound gel, and some other stuff. I was so impressed and so appreciative!! I wish I could thank each person individually who helped put the supplies together for us. The networking that has been happening on the ground is very cool and truly amazing to watch.

linking

2010-02-14T22:46:00.003-06:00

Check it out: We Are The World 25 for Haiti

Images and video from the city, hospital, and clinic HERE and HERE.

An article written about our first week is HERE (yes I was completely misquoted throughout essentially the entire article--but the gist of the article is good and the reporter was a nice guy).

Dr. Pete Melchert just returned from volunteering with Heartline. Watch a news story about him HERE.

I will admit--for someone who is generally a very private person it is strange to suddenly have any part of my life be so public. But this is a story that needs to be told, and I want to keep telling it.

Some of my Facebook updates from the past few days:

--another little aftershock this AM while I was just waking up...it felt small maybe a 4...but it was enough that Geronne told me she was about to come and drag me out of bed outside. nerves are still jittery here.

--I fell asleep this afternoon while riding in the car with a kid on my lap and going over huge bumps in the road. I think I'm a little sleep deprived.

--a great team of people left today, with another fantastic team replacing them...we have a new ortho PA, new PT, 3 new RNs, new medic, and a new med/peds doc. there are also several RNs who have been here for awhile and can train in the new RNs

--another patient we sent to the USNS Comfort came back for a follow up visit today...she's doing great...it makes me so happy to see kids (who had horrible quake injuries) doing so well

--to all of you who were here at the beginning...Patrick is back, and he's just as sweet as he was when we first met him. he remembered me right away when we picked him up today and he even remembered my name. it feels like we've come full circle

--the truck picked up 2 gunshot wound patients from Cite Soleil today and brought them back to the hospital--the story is that the police were firing their weapons into the ground in an attempt at crowd control, and the people were hit by these bullets. thankfully their injuries are not life-threatening.

--we have patients currently on nitro and IVIG drips at the hospital...we are replicating 1st world medicine as much as we possibly can...under tarps in the front yard of a house. it's amazing stuff :)

things that keep you going

2010-02-09T20:17:00.007-06:00

--The Thursday flight is bringing in these medical volunteers: 2 RNs (with 1 other pending), 1 physical therapist, 1 med/peds doctor, 1 midwife, 1 paramedic, 1 ortho PA (I got a blog comment from Amy at 4:30 PM that showed up on my Blackberry, I called her as soon as I got the comment, and she was confirmed on the flight a few hours later. Very cool). 24 hours ago we had no medical volunteers confirmed on this flight. I can breathe now.

--Dr. Pete tracked down some much-needed medications and supplies recently. They've been crucial in managing a few of our patients. We currently have one patient on a nitro drip and another on an IVIG drip. This is 1st world medicine being practiced outside under tarps and on the house's porch. There are some incredible people here right now making all of this possible (Dr. Pete and Emily the pharmacist, as well as many very skilled nurses come to mind).

--2 babies were born at Heartline yesterday. Both came very quickly. Both moms and babies (1 girl and 1 boy) are doing well. Both moms did great. I was at the first birth and got to put my NPR skills to good use for the 2nd time since I've been here. Neonatal resuscitation is very satisfying, because most babies do well.

--I feel like a broken record in saying this: I am so blown away by the environment at our field hospital (Heartline Hospital). We have 30+ patients (plus family members) sleeping on cots outside under tarps. It's very primitive. But that doesn't matter--patients are being cared for with skill and compassion. There is such a feeling of healing, grace, and community as you walk through the cots and interact with the patients and families. We've been sending many of our long-term patients to another facility for skin grafts and other operative interventions. When they come back post-operatively, it feels like a little homecoming. The fact that we have a lot of pediatric patients here helps--they keep the atmosphere light and they keep all of us laughing (below is Fritz, the little boy featured in KSTP's story yesterday...as you can see his face is healing up great).

--Along those lines...I continue to be grateful for and amazed by the connections we've made with other organizations. We've send a total of about 60 patients to other facilities for surgical intervention. These patients have gotten care onboard the USNS Comfort, at the University of Miami Medishare Hospital at the airport, at the MERLIN facility in Delmas, at Double Harvest, at CDTI/Sacre Coeur in downtown, and at L'hopital Communite in Petionville. We've also taken many post-operative patients back from these facilities. The cooperation is encouraging. They help us by doing surgery on our patients, and we try to take back our own post-operative patients as well as other post-op patients that need a place to go for wound care and rehab. Our patients are receiving first-class care by skilled and compassionate surgeons, other physicians, and nurses at these other facilities. I am beyond thankful for their help.

--I'm fairly sure that we're going to be getting a post-op patient off of the USNS Comfort tomorrow who was one of our 1st patients way back on 2/18 (the first day we had clinic). He is a teenage boy who had an open tib/fib fracture that we reduced as best we could in our ER/OR. He ultimately went onboard the Comfort for definitive surgical care. He is such a neat kid--I can't wait to see him again.

And something not in the category of "things that keep you going":
--Leaving is going to be very, very hard. I feel like I could stay busy here for months just dealing with earthquake-related medical needs (let alone non-quake related medical stuff)...how do you walk away from work that still needs to be done?? I've traveled back and forth to Haiti 20+ times since 1998. With the exception of my first couple trips, it's always been much easier for me to come to Haiti than to leave Haiti. I hate leaving this place. But I have a job to go back to.

personnel needs--UPDATED

2010-02-05T09:52:00.004-06:00

I am looking for people to fill 4 positions starting on Thursday, February 11th. If you are interested in volunteering and meet these qualifications, please contact me ASAP at halv0105 AT umn DOT edu.

I sincerely appreciate everyone who's contacted me about volunteering in a number of roles. If you have not heard back from me yet, please be patient. We may still have an opening for you in the future. For now, please only contact me if you meet the qualifications for these 3 specific positions.

For each of the positions, you must have previous experience in the developing/3rd world. Preference would be given to those who speak Kreyol.

Thanks in advance for being willing to help out!

1. Orthopedic physician assistant (PA):
You would serve as our orthopedic consultant. We have a large number of patients with fractures, including fractures complicated by overlying wounds. We have many patients in casts who need frequent cast care including the cutting of cast windows and cast reinforcement. We are following several patients with external fixators in place. Together with the inpatient doctor, you would provide care for these patients including providing guidance for long-term management, doing cast changes and wound care, and collaborating with the physical therapist formulating long-term treatment plans. Our current ortho PA has also been assisting with dressing changes, doing minor procedures (abscess I&D, suturing, etc), and seeing new trauma patients. You will need to commit for a minimum of 10 days, but it would be preferable if you could stay for 2 weeks or longer.

2. Physical therapist (PT):
Many of our patients have severe orthopedic injuries and are non-ambulatory. Many have undergone surgery. We have many other patients including amputees, patients with large wounds, and patients at risk for contractures (due to burns or other severe injuries). All of these patients need intense physical therapy while hospitalized. You will need to commit for a minimum of 10 days, but it would be preferable if you could stay for 2 weeks or longer.

**3. Med/Peds MD or Family Medicine MD (ADDED SATURDAY):
You would be in charge of running the inpatient ward along with a team of nurses and other support staff. We typically have 20-30 inpatients. The days begin early with morning rounds, followed by many hours of wound care and dressing changes, including some sedated procedures. Evening rounds are typically done with the nurses around 7 PM. You should be skilled and comfortable doing minor procedures (suturing, I&Ds, digit amputations) and sedations (using Ketamine and possibly Versed). You should have a strong background in orthopedics. The ability to apply and remove casts would be very beneficial, though not necessary. In addition to trauma patients, you will also care for medical patients of all ages with a variety of problems (acute febrile illnesses, dehydration, pneumonia, bronchiolitis, malnutrition, heart failure, etc). Additional training in tropical and travel medicine would be beneficial, and you must have previous medical experience in the developing world. Conditions here are primitive, with only limited access to labs and x-rays, though we do have a very good supply of a variety of medications. The hospital itself is in a house that used to be a children's home. It is a very special place of healing, and there is a strong sense of community amongst the patients and providers.

4. Emergency medicine/logistics (someone to replace me):
Initially, I was doing a lot of hands-on medical work alongside the other medical providers here. I continue to do some hands-on work, but at least half of my time is now spent on logistics. This involves continual assessment of the clinic/hospital's personnel and supply needs, communicating with and recruiting volunteers, coordinating medical volunteer schedules (nurses, physicians, PAs, PTs, and EMTs), maintaining inventories of supplies and medications, tracking down needed supplies and medications, coordinating the transfer of patients both to and from various other hospitals, communicating with the medical personnel at referring hospitals (including arranging for surgical procedures on the appropriate patients)...and a hundred other things.

The ideal person would have extensive past experience working in Haiti, be able to stay for 4 weeks or longer, be able to speak at least some Kreyol, and would know their way around Port au Prince.

Ideally this person should be an MD, preferably with an emergency medicine background (to serve as the back-up physician to the inpatient hospitalist), but I also think this job could potentially be done by a non-MD with other medical experience (hospital/clinic administration, etc), as long as the other requirements are met. I am not leaving until February 16th, but I would like this person to arrive on the February 11th flight so I can start handing the job over.

more connections

2010-02-04T20:57:00.003-06:00

Sometimes it feels like half the battle of the past 3 weeks has been finding the right place to send people who need surgery. The options are infinitely better now than they were at first (when there really were no options and we were temporizing things ourselves). It's still not easy, though, as most places taking surgical patients are full (or nearly full). Everyone at these hospitals is working their butts off---but the sheer number of patients who need surgical intervention is overwhelming.

We've been able to make connections with various places and organizations, usually through word of mouth or someone who knows someone who knows someone etc. There is a nurse here named Wes who spent his first week in Haiti volunteering with an organization called Merlin. They've set up a tent hospital with ORs not far from Heartline, and they currently have plastics and ortho surgery capabilities. Wes hooked us up with them, and it's been an awesome connection. The main guy we're in contact with there is great and he's been super helpful.

We brought a sweet little boy there yesterday who was missing a big chunk of skin from the back of his hand (a concrete block fell on his hand in the quake, he pulled his hand out and the skin ripped off). He had a skin graft surgery today (they took a piece of skin from his thigh and transplanted it to his hand). We went back and picked him up tonight and he was awake, happy, and smiling. His hand and thigh are bandaged and we won't take them off for another week. He'll stay in our hospital for the next week so he can get antibiotics, pain meds, food, and a lot of TLC. I can't wait to see this little guy's new skin graft! His surgery today likely saved him from a lifetime of having a not-fully-functional hand. Thanks MERLIN!!

We transported another woman to them today who needs skin grafting, and we have several more we're planning to bring as well. In exchange, we're helping them by providing inpatient post-op care for some of the patients they have operated on. We took 2 of their post-ops yesterday, and will plan to take a couple more tomorrow. As we have space, we'll continue to try and help them out. We also received 2 post-op patients from the USNS Comfort today--we'll be providing for their needs (medical & otherwise) until they're ready to be discharged home. I'm really happy that we're able to help in this way---all of these organizations (Comfort/Navy, MERLIN, University of Miami/Medishare, and others) have graciously accepted our surgical patients over the past several weeks---and we want to do whatever we can to help them out. The quicker they can clear out post-op patients, the quicker they can take in more new surgical patients.

and so it goes

2010-02-04T09:46:00.004-06:00

The past week passed quickly--a lot has happened and a lot has changed since I last updated. We've had a couple new teams of people come in and many people have since left, including the Livesays last night. I've known the Livesays for the past several years and they've become some of my best friends. I lived with them in Haiti back in 2008 and I've been staying at their house since I arrived a little less than 3 weeks ago. Being able to go home to their house at the end of each of our very long days has made all of this a lot easier. They "get" me, we laugh at the same stuff, we find the same things annoying, etc etc etc. You know what I mean. I think in the midst of all the things we're seeing and doing you need people around you with whom you can completely be yourself. They're in the states now taking a much-needed break to be with their kids. T&T...YOU ARE MISSED.

The clinic/ER and hospital continue to be very busy most days. Every now and then we'll have a day in clinic (like today) that's a little less busy, but it's always invariably followed by a busy day. Dr. Peter Melchert, a med/peds hospitalist from Minnesota, arrived last week and has done an amazing job of organizing the hospital/inpatient ward. He is completely in charge over there and I couldn't be happier about that. We also have an incredible team of nurses who are working 12 hour shifts day & night providing compassionate, healing care to the 30+ inpatients. A couple days ago we had 15-20 inpatients. Last night I believe we had 35. A couple days ago we were actively seeking out other hospitals that needed a place to send their post-op patients for ongoing care, because we had the space, personnel and supplies to take care of them. Now we're figuring out which patients we can send home to make room for more. This is hard to do when many of your patients don't have any house to go home to. I know of at least 3 post-op patients we will need to find room for by later this afternoon.

I'd estimate that about half of the patients we're seeing have earthquake-related injuries and about half do not. Of the half that do not, we're seeing a variety of things: presumed malaria, dehydration, malnutrition, pneumonia, possible guillan-barre syndrome, and presumed post-partum cardiomyopathy. For the patients with wounds, daily dressing changes are being done. With the frequent dressing changes, most of the wounds are looking pretty "good" currently (many are still big and gaping, but they're clean and not infected) and are healing well.

Don and John are also still taking the big truck out into various neighborhoods every day. We're typically sending 1-2 EMTs and a nurse on the truck. They're doing a lot of wound care out in the field. People with more serious wounds/illnesses are transported back to the clinic/ER for more extensive care, and it's not unusual that we end up admitting several of them each day.

Everything is unpredictable (What else is new? This is Haiti). One of the most difficult things I've been dealing with is trying to get the right number of people (and the right kind of people) down here to help. I could write a book about the whole process, but I'll spare you. Suffice it to say that it's been hard.

What else...we now have a good supply of tetanus vaccine, thanks to the UN and Peter. We've been vaccinating every unvaccinated person who comes through the clinic, even if they're not injured. We have a great supply of medications. There are a few meds we're going through quickly, but we have enough. Our stock of medical supplies, with a few exceptions, is good. Please don't hear this as a complaint, because it's not, but we're now dealing with having too many supplies now. Well-meaning people have been sending a lot of stuff that we either don't need or can't use. We still want to be good stewards of these supplies as best as we can, so we're trying to get them to people who can use them, but that takes time and coordination.

I have many stories in my head to share...but no creativity left in me. Tara has written about patients we've seen here and here and here.

As for me...I'm tired (physically, emotionally, etc). I haven't been able to take a day off since I got here but hoping to this weekend. I'll be fine...I've got a little vacation coming up after I'm done here and I can sleep then. I'm well aware of the fact that my life is easy compared to most here.

too tired to say much

2010-01-29T21:13:00.003-06:00

There are many stories to tell but not enough time to tell them. We are still seeing open, infected, gangrenous wounds that were sustained in the earthquake. We are still transferring several patients a day to various hospitals for more definitive surgical care. The medical professionals at the University of Miami/Medishare tent hospital at the airport have been incredibly helpful. They have not turned away any patients we've brought to them, and for that I'm extremely grateful. We have over 20 patients in our inpatient ward and a terrific team of nurses caring for them 24/7. We are seeing several kids each day with vomiting, diarrhea, and dehydration, as well as some with significant malnutrition, neither of which are unexpected.

I wish there were more hours in the day, more time to write out all that we are seeing. In lieu of my writing...
Here is Heartline's blog describing some of what we're doing day-to-day.

If you've e-mailed me recently about volunteering with Heartline, please know that I so appreciate your willingness to help out. We are in the process of assessing our current staffing needs, patient volumes, and future plans for Heartline Clinic--and we are also planning the next chartered flight into Haiti. Once all of these details are worked out, I will be contacting people who have expressed interest in volunteering. Thanks for your patience!

For those in Haiti: we need emergency medicine MDs/PAs for the next few days

2010-01-28T06:06:00.002-06:00

I was supposed to have 2 ER doctors on today’s flight but both of them were unfortunately unable to travel to Fort Lauderdale in time for the flight. We're working on trying to get them on the next available flight.

Yesterday was extremely busy. There is no way we can keep up the volumes that we’re seeing without the appropriate number of staff. If anyone knows of any ER docs (or ER physician assistants/NPs, or people with a similar skill set) currently in Port au Prince who could help us out for a few days, PLEASE send them our way. I’m mainly looking for people who are able to do sedations (i.e. push sedation meds like Ketamine and Versed) and do procedures (major wound/burn debridements, abscess I&Ds, suturing, splinting, casting, and so on). My Haiti cell is 3480-2914 and e-mail is halv0105 AT umn DOT edu.

Thanks everyone.

crazy busy day

2010-01-27T22:27:00.004-06:00

We thought things were going to start calming down. In retrospect, I'm not sure why we thought that. It's not happening. We continue to see wounds that haven't had proper care. We're also seeing a lot of people who've had previous surgical care but no follow up.

Read Tara's post about today here.

If you've e-mailed me about volunteering or donating supplies and haven't heard back, please be patient. I will get back to you as volunteer spots open up. Thanks again to all of you for being so willing to help out!

supply needs--clarification

2010-01-27T11:27:00.001-06:00

In regards to the supply needs I posted below--thanks to everyone who's offered to help. If you are already planning to come into Haiti soon, these are some supplies you could bring with you for us. Or, if you are already here and know where to get supplies, we'd love to know about that. Otherwise, it's going to be too hard/expensive for people to purchase supplies and then try to get supplies to us (this involves shipping things to Florida then on a plane to Haiti).

There was an ENT doctor who happened to stop by yesterday and today. We had a child with what we thought was pre-septal (periorbital) cellulitis. He initially got better on IV antibiotics, but then got worse. On the day he got worse, the ENT doctor happened to stop by. The ENT was very worried about a post-septal abscess (orbital abscess/cellulitis). Yesterday he cut the child's lateral canthus to relieve pressure on the eye, and today he did an I&D and drained a large abscess that was full of nasty pus. He just saved this child's eye. And we did it all on our plastic folding tables that are our OR tables, with ketamine sedation, and it went great. I'm in awe. The child will stay with us for about 10 days to get IV antibiotics.

I'm still looking for either an ER doctor or ER PA (preferably with a lot of ortho experience and previous 3rd world medical experience) to leave on tomorrow's flight and stay for at least a week. I have a couple leads but if anyone else is available, please e-mail me: halv0105 AT umn DOT edu. Thanks. Again, please only e-mail regarding this specific staffing need. I will post additional staffing needs as they come up.

Thanks again to everyone for all the support, comments, messages, etc. You guys are great!

supply needs

2010-01-26T20:26:00.003-06:00

We are officially now well-stocked with medications and medical supplies. THANK YOU to everyone at Children's who helped with gathering the supplies and donating money to pay for them! Emily, Rob Sicoli, David Hirschman, plus many EMTs, nurses, HUCs and others all helped out to get a great stock of meds & supplies from MN to Haiti, and we are so grateful! It's great to not have to worry about supplies and medication anymore, and to not have to spend time tracking them down.

We also received a large amount of medication and supplies from the United Nations. Liz Carl, a long-term missionary in Haiti who works with the UN, came by yesterday with a list of available meds/supplies and asked me to write down what I needed. I filled out a whole sheet with my requests and sent it off. I will admit---I was a little skeptical that the supplies would actually be delivered, but they came back today with every last thing that I ordered---all completely free of charge. Huge thanks to Liz and the UN for helping us out!

Our current supply needs reflext the fact that we're starting to do more longer-term inpatient care and comparatively less acute/emergency care (though we're still seeing a fair amount). We now have a 20+ bed inpatient unit full of many people who lost their homes and everything in them. They often come to the clinic wearing their only clothes, having not eaten for several days. We need to be able to house, feed, and care for them (as well as their physical wounds/injuries).

If anyone is coming into Haiti, or is in Haiti and knows where we can get these things, please let me know. Here's what we need:

Walkers

Crutches

Mattresses or cots

Plastic mattress covers (or we think shower curtains would work well too if we duct taped the corners)

Sheets

Towels

Clothing for all ages (nice clothing please---it doesn't have to be brand new, but it should be nice--please don't bring worn out clothing or clothing with holes)

Hygeine packs for patients (Big Ziplok bag with soap, toothbrush, toothpaste, shampoo, washcloth, etc in it)

Snacks bags for patients (cookies, crackers, juice box, candy, etc)

We brought a little girl to CDTI/L'hopital Sacre Coeur today. The last time I was there was when the Livesay's daughter Lydie had bacterial meningitis back in January of 2008. It was weird to be back, both because of the memories of when Lydie was there, and also because of how different it looks now. It's been mostly taken over by various international groups and they're doing a lot of orthopedic surgery. The hospital has some damage and some pretty big cracks in the walls. Back in 2008 they had this little indoor pond on the 1st floor (yes--in Haiti. yes it's strange) with fish and turtles in it. It's all still there--turtles included.

For more about today...see Tara's post here. We drove through downtown Port again (to get to CDTI) and it was depressing. I've driven by the palace numerous times now but each time is still a little bit shocking. The tent cities all over Port are growing bigger every day. It's the dry season right now but rainy season starts in a few months. Then what? Most of the people living in these tents have no home to go back to. I can't imagine that any of these tent cities have running water or sanitation or anything like that. It's a huge problem that's only going to get bigger over time.

Despite all that...it's good to be here. I'm working with some amazing people and staying with some of my best friends. Greg Erickson from Providence arrived today and is going to be helping Troy with driving, fixing things, and stuff like that. People back home and all over the world have been amazingly supportive.