Every morning a flatbed named despair drives out of the Heartline Ministries compound and into the slums of Port-au-Prince, looking for the injured in need of help. When the truck returns several hours later and slides through the steel rollaway gates that guard the compound, a small medical staff goes to work.
Since last Thursday, some of the injured are being treated by my colleague, Dr. Peter Melchert, an internist and pediatrician working at Abbott Northwestern Hospital and Children’s Hospital in Minneapolis. What Melchert and others are primarily treating is the crush wound, the hallmark injury from what Haitians now refer to simply as “Tuesday.”
“That’s the story we hear time and time again, that I was next to a wall, a wall of cinder blocks, and it came down on top of me. And that’s the story, no matter what the age of the patient is,” Melchert told me by phone on Friday.
Crush wounds involve two basic types of injuries: fractured bones, and extensive tissue damage, particularly if the limb was under pressure for a long time. Push your thumb down on your skin for few seconds and then pull it off: The blanching you see is where the pressure of your thumb prevented blood flow to the area. Imagine how much blanching a slab of concrete can do if it’s on a limb for a prolonged period, particularly if your blood pressure is low because of dehydration.
“I saw a 19-year-old girl today, where, when the school she was in collapsed, the only thing that was really stuck was her left hand — for three days,” Melchert recalled. Of the 30 students in the classroom, she was the only one to survive, but the skin on her hand eventually died under the prolonged pressure. By the time Melchert treated her, “Her hand was enormously swollen and secondarily infected. We’re essentially treating it like a severe burn.”
As if the young woman’s hand injury wasn’t enough, Melchert noted that she couldn’t lift up her left foot. “She told us this story that when the building collapsed on her, a male classmate next to her was killed instantly and fell with his head on her knee.” Either due to the initial blunt trauma, or because of prolonged pressure, the nerve that pulls the foot up was injured.
As an active member of Children’s Surgery International, Melchert has cared for sick children in the most destitute of places (including Port-au-Prince a year ago), but he’s never been exposed to such devastation and the way it can complicate caring for the injured.
“The saddest thing about it is that we’re still picking up fresh cases, and we’re entering the third week following the disaster, seeing people that have just been lying in their home or in a tent, getting no care — nothing,” Melchert lamented. “People aren’t lining up at our door because they can’t get to us. They don’t have transportation. There isn’t an ambulance system or anything, so we go find them. More than two weeks into this calamity and there’s people with broken bones, and/or open, gaping, infected wounds — we’re talking big wounds — and they’ve not received any care.”
And so twice a day the field hospital’s truck heads out to the tent cities and returns with 15 to 20 patients. Melchert estimates that all but 5 percent of those people are being evaluated for the first time, sometimes because they have no one left to advocate for them.
“We’re treating a 4-year-old that was stuck under a collapsed building for several days, all by himself. His whole family was killed except for his grandmother. He’s got a broken arm, a broken leg, and an open skull fracture with an accompanying head wound that needs daily dressing changes.”
Becoming what you need to become
When the earthquake struck, Heartline Ministries quickly converted its three buildings — a boys’ orphanage, a girls’ orphanage, and a school for teaching trade skills to young women — into a field hospital.
Melchert says that another Minnesota physician, Dr. Jennifer Halverson, is coordinating the mission’s medical efforts. “She’s been down here since the beginning of the incident and she’s really running the whole medical operation, and organizing it all. She’s an emergency medicine fellow at Children’s [Hospital in Minneapolis]. She’s very skilled, speaks Creole, knows the Haitian culture, and is just doing remarkable things.”
For the wide variety of clinical experience Melchert has, he wasn’t quite prepared for what calamity and necessity would require of him.
“If you had told me 24 hours ago that I would be doing this kind of stuff, I would have never believed it,” Melchert admitted. “I’m basically doing the job of an anesthesiologist and then the surgeon. I put them to sleep, I debride [clean up] the wound, and then they wake up and I admit them to the hospital.” Everyone on the small medical team — including a physical therapist, three emergency-room nurses from Children’s Hospital, and an orthopedic physician’s assistant with extensive experience treating blast injuries in Iraq — is feeling stretched.
“It’s a much more multidisciplined effort here than I ever thought. Nurses are taking on doctors’ roles. Me as a general doctor taking on other doctor roles — part anesthesiologist, part surgeon. Everybody is really needing to work independently and efficiently, and yet we rely on each other’s special skills, too,” Melchert told me. “The people who are down here are truly amazing — really talented, gifted people, working almost endless hours and being willing to work more. And doing it under very trying circumstances.”
After care: warding off life-threatening wound infections
Most of those who sustained acute, life-threatening injuries during the quake died quickly thereafter. But those with deep, complicated wounds will remain at risk for serious life-threatening infections until the wound is healed, and that could take weeks or even months. Making that happen will take a different approach from the health-care community reaching out to Haiti. According to Melchert, that transition is just beginning to take place.
“When you hear about the need for people, it’s always saying we just need surgeons. I think that’s important in the early part of this, but what’s being missed is the after care: the meticulous, long-term observation and wound care and management, trying to prevent infection, and keep them nourished. I think we’re moving into a stage where there’s a need for that multidisciplinary approach.”
What does meticulous wound care entail? It means using pain medications and anesthesia so that the wound can be humanely worked on. It means tediously removing, as Melchert describes with frustration, the hundreds of cinder block fragments and other debris that have been pounded into the wound and which can act as “safe houses” for bacteria. It means removing tissue that has been devitalized to the point where it can only provide food for bacteria. It means washing out the wound with anti-septic fluids, and because wounds this complicated cannot be physically sterilized, using antibiotics to finish the job. It means adequate nutrition. It means scheduled dressing changes, some once a day, and some every few days. And a bad wound over a fractured bone presents a special problem because a cast obviously doesn’t allow ready access to a wound. Melchert has removed old casts placed somewhere else only to find a very ugly surprise.
There are plenty of logistical problems for a makeshift hospital in Port-au-Prince: electricity (Heartline has a generator), transportation, food and medical supplies. But the devastation has created one more: Some patients are unwilling (or perhaps, more accurately, unable) to be hospitalized, no matter how severe their injury.
“A 30-year-old woman came in last night, 17 days after the disaster, and she had this gaping wound over her knee. She could barely bend her knee, so we thought the knee joint was infected as well; her thigh was twice the thickness of her other thigh,” described Melchert. “We did some initial treatment, and she needed a lot more. But she had to go home, because she left her 4-year-old to supervise the 10-month old. There’s no one else there — everyone else is dead. So she had to go home. She refused to be admitted.”
“Tuesday” has left Haiti wounded in so many ways.
Bless these doctors, and Doctors Without Borders, and all the other medical professionals who have shown up in Haiti since the quake — beginning with those doctors from Venezuela and the Dominican Republic who were able to come at once.